Healthcare Provider Details

I. General information

NPI: 1851914386
Provider Name (Legal Business Name): NEEDVILLE FAMILY DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12815 HIGHWAY 36
NEEDVILLE TX
77461-8112
US

IV. Provider business mailing address

PO BOX 1627
NEEDVILLE TX
77461-1627
US

V. Phone/Fax

Practice location:
  • Phone: 979-793-5566
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. JENNIFER KUNKEL
Title or Position: PRESIDENT
Credential: DDS
Phone: 979-793-5566