Provider Demographics
NPI:1013323732
Name:DENTON SHK DENTAL PC
Entity Type:Organization
Organization Name:DENTON SHK DENTAL PC
Other - Org Name:1ST SMILE DENTAL CARE OF DENTON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDY
Authorized Official - Middle Name:H
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:KATIE BAE
Authorized Official - Phone:214-736-3777
Mailing Address - Street 1:1800 BRINKER RD STE 290
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76208-6179
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 BRINKER RD STE 290
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76208-6179
Practice Address - Country:US
Practice Address - Phone:214-736-3777
Practice Address - Fax:972-570-3776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27677122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX298227402Medicaid