Healthcare Provider Details

I. General information

NPI: 1245772995
Provider Name (Legal Business Name): 4K DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21434 PROVINCIAL BLVD
KATY TX
77450-7587
US

IV. Provider business mailing address

21434 PROVINCIAL BLVD
KATY TX
77450-7587
US

V. Phone/Fax

Practice location:
  • Phone: 281-398-4369
  • Fax: 281-398-4328
Mailing address:
  • Phone: 281-398-4369
  • Fax: 281-398-4328

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number32432
License Number StateTX

VIII. Authorized Official

Name: DR. ANTHONY OLULAJA OLAYIWOLA KOFOWOROLA-KUTI
Title or Position: CLINICAL DIRECTOR
Credential: DMD; MPH; BDS; CCRC
Phone: 336-354-9314