Provider Demographics
NPI:1851773857
Name:MINI APPLE DENTAL ENTERPRISE PLLC
Entity Type:Organization
Organization Name:MINI APPLE DENTAL ENTERPRISE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:SISOMBATH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-735-3712
Mailing Address - Street 1:911 N SYLVANIA AVE
Mailing Address - Street 2:SUITE #150
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-2459
Mailing Address - Country:US
Mailing Address - Phone:612-735-3712
Mailing Address - Fax:972-329-7000
Practice Address - Street 1:911 N SYLVANIA AVE
Practice Address - Street 2:#150
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111
Practice Address - Country:US
Practice Address - Phone:612-735-3712
Practice Address - Fax:972-329-7005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX25064OtherLICENSE