Provider Demographics
NPI:1649544966
Name:FALL CREEK DENTAL PA
Entity type:Organization
Organization Name:FALL CREEK DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:LADAWN
Authorized Official - Last Name:MCFADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-326-5717
Mailing Address - Street 1:5600 N GATE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76049-3120
Mailing Address - Country:US
Mailing Address - Phone:817-326-5717
Mailing Address - Fax:817-326-5714
Practice Address - Street 1:5600 N GATE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-3120
Practice Address - Country:US
Practice Address - Phone:817-326-5717
Practice Address - Fax:817-326-5714
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX009483101Medicaid
TXB19566OtherDELTA DENTAL CHIPS