=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033914965
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAHOKA DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2025
-----------------------------------------------------
Last Update Date | 02/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2428 LOCKWOOD STREET
-----------------------------------------------------
City | TAHOKA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-601-0333
-----------------------------------------------------
Fax | 806-601-0339
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1310 ESSEX LANE
-----------------------------------------------------
City | WOLFFORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79382
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-448-2346
-----------------------------------------------------
Fax | 806-507-3037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. BENJAMIN ROY MENLOVE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 801-448-2346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------