Provider Demographics
NPI:1841606381
Name:MIDNITE DENTAL, PLLC
Entity Type:Organization
Organization Name:MIDNITE DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KLAUS
Authorized Official - Middle Name:JOHANN
Authorized Official - Last Name:RADTKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-225-6675
Mailing Address - Street 1:PO BOX 3126
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78502-3126
Mailing Address - Country:US
Mailing Address - Phone:415-225-6675
Mailing Address - Fax:
Practice Address - Street 1:801 E NOLANA AVE
Practice Address - Street 2:SUITE # 14
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-6104
Practice Address - Country:US
Practice Address - Phone:415-225-6675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-04
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX26256122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2804890Medicaid