Provider Demographics
NPI:1972877959
Name:CABAL GROUP INC.
Entity Type:Organization
Organization Name:CABAL GROUP INC.
Other - Org Name:LAKE COUNTRY ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CIRO
Authorized Official - Middle Name:
Authorized Official - Last Name:CABAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-236-7846
Mailing Address - Street 1:5800 BOAT CLUB RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-7773
Mailing Address - Country:US
Mailing Address - Phone:817-236-7846
Mailing Address - Fax:
Practice Address - Street 1:5800 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-7773
Practice Address - Country:US
Practice Address - Phone:817-236-7846
Practice Address - Fax:817-236-3354
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CABAL GROUP INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-08
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201272602Medicaid