Healthcare Provider Details

I. General information

NPI: 1366777625
Provider Name (Legal Business Name): NTKC-DFW, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2009
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 HILL BLVD SUITE 102
GRANBURY TX
76048-1481
US

IV. Provider business mailing address

3801 WILLIAM D TATE AVE STE 105
GRAPEVINE TX
76051-8755
US

V. Phone/Fax

Practice location:
  • Phone: 817-294-0280
  • Fax: 817-294-2084
Mailing address:
  • Phone: 817-488-6812
  • Fax: 817-251-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: DAN BACCUS
Title or Position: CFO
Credential:
Phone: 817-488-6669