Provider Demographics
NPI:1811399678
Name:DYNAMIC X-RAY INC.
Entity Type:Organization
Organization Name:DYNAMIC X-RAY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENNY
Authorized Official - Middle Name:J
Authorized Official - Last Name:ILLICKAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-352-7260
Mailing Address - Street 1:291 STONE MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:TX
Mailing Address - Zip Code:75182-2655
Mailing Address - Country:US
Mailing Address - Phone:972-352-7260
Mailing Address - Fax:
Practice Address - Street 1:4230 LBJ FWY
Practice Address - Street 2:STE, 111
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5806
Practice Address - Country:US
Practice Address - Phone:972-352-7260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX246XS1301X, 247100000X, 2471C3402X, 2471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistGroup - Multi-Specialty
No246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonographyGroup - Multi-Specialty
No2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiographyGroup - Multi-Specialty
No2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonographyGroup - Multi-Specialty
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular SonographyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX=========OtherEIN