Provider Demographics
NPI:1841561164
Name:HUCKMAN DENTAL PROFESSIONALS, PLLC
Entity Type:Organization
Organization Name:HUCKMAN DENTAL PROFESSIONALS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KOENEG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:361-243-6242
Mailing Address - Street 1:106 E CORPUS CHRISTI ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:BEEVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78102-5600
Mailing Address - Country:US
Mailing Address - Phone:361-358-5151
Mailing Address - Fax:361-358-5524
Practice Address - Street 1:106 E CORPUS CHRISTI ST
Practice Address - Street 2:SUITE C
Practice Address - City:BEEVILLE
Practice Address - State:TX
Practice Address - Zip Code:78102-5600
Practice Address - Country:US
Practice Address - Phone:361-358-5151
Practice Address - Fax:361-358-5524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22869122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2146748-02Medicaid