Provider Demographics
NPI:1871037697
Name:KIDS DENTISTREE OF ABBEVILLE - ODESSA, PLLC
Entity Type:Organization
Organization Name:KIDS DENTISTREE OF ABBEVILLE - ODESSA, PLLC
Other - Org Name:KIDS DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8500
Mailing Address - Street 1:400 S IKE AVE
Mailing Address - Street 2:
Mailing Address - City:MONAHANS
Mailing Address - State:TX
Mailing Address - Zip Code:79756-4735
Mailing Address - Country:US
Mailing Address - Phone:432-580-7220
Mailing Address - Fax:
Practice Address - Street 1:400 S IKE AVE
Practice Address - Street 2:
Practice Address - City:MONAHANS
Practice Address - State:TX
Practice Address - Zip Code:79756-4735
Practice Address - Country:US
Practice Address - Phone:432-580-7220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-13
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty