Provider Demographics
NPI:1891018297
Name:TEXAS ORTHODONTICS FOR KIDS, PC
Entity Type:Organization
Organization Name:TEXAS ORTHODONTICS FOR KIDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:972-564-6064
Mailing Address - Street 1:215 S FM 548
Mailing Address - Street 2:A
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126
Mailing Address - Country:US
Mailing Address - Phone:972-564-6064
Mailing Address - Fax:
Practice Address - Street 1:215 S FM 548
Practice Address - Street 2:A
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126
Practice Address - Country:US
Practice Address - Phone:972-564-6064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX00244861223X0400X
TX00208021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1306969894OtherNPI
TX1861628638OtherNPI