Provider Demographics
NPI:1740569144
Name:ABC123 DENTAL IN HALTOM PLLC
Entity Type:Organization
Organization Name:ABC123 DENTAL IN HALTOM PLLC
Other - Org Name:ABC123 DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TRI
Authorized Official - Middle Name:H
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-656-1215
Mailing Address - Street 1:5416 BASSWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-4400
Mailing Address - Country:US
Mailing Address - Phone:817-656-1215
Mailing Address - Fax:877-687-6861
Practice Address - Street 1:5416 BASSWOOD BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-4400
Practice Address - Country:US
Practice Address - Phone:817-656-1215
Practice Address - Fax:877-687-6861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty