Provider Demographics
NPI:1700168192
Name:IKIDS PEDIATRIC DENTISTRY ARLINGTON
Entity Type:Organization
Organization Name:IKIDS PEDIATRIC DENTISTRY ARLINGTON
Other - Org Name:WEECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF REVENUE & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:AGUILAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-466-8554
Mailing Address - Street 1:2500 E BROAD ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4361
Mailing Address - Country:US
Mailing Address - Phone:817-466-8554
Mailing Address - Fax:
Practice Address - Street 1:3801 S COOPER ST STE 109
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76015
Practice Address - Country:US
Practice Address - Phone:817-467-9089
Practice Address - Fax:817-472-9008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242721223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200886401Medicaid
TX200886404Medicaid
TX200886402Medicaid
TX200886403Medicaid