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General NPI Number Information
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NPI Number | 1225282320
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Entity Type | Organization
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Legal Business Name | KTV DENTAL , PA
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Dates
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Enumeration Date | 11/17/2008
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Last Update Date | 11/17/2008
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Provider Practice Location Address
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Address Line | 2717 8TH AVE.
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City | FORT WORTH
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State | TX
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Zip | 76110
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Country | US
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Telephone | 954-591-0298
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Fax |
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Provider Business Mailing Address
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Address Line | 2530 SARA JANE PKWY APT 333
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City | GRAND PRAIRIE
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State | TX
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Zip | 75052-8604
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Country | US
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Telephone | 954-591-0298
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KIM THI VAN
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Credential | D.M.D
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Telephone | 954-591-0298
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 23133
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License Number State | TX
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