Healthcare Provider Details

I. General information

NPI: 1619427002
Provider Name (Legal Business Name): WOW FAMILY DENTAL P.A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2016
Last Update Date: 10/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3306 W CAMP WISDOM RD STE. 100
DALLAS TX
75237-2596
US

IV. Provider business mailing address

1801 PRECINCT LINE RD STE. A
HURST TX
76054-3170
US

V. Phone/Fax

Practice location:
  • Phone: 817-577-9200
  • Fax:
Mailing address:
  • Phone: 817-577-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20467
License Number StateTX

VIII. Authorized Official

Name: DR. KAIVAN AFKAMI
Title or Position: OWNER
Credential: DDS
Phone: 817-577-9200