=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265222566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KITTY HAWK FAMILY DENTISTRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2025
-----------------------------------------------------
Last Update Date | 05/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7875 KITTY HAWK RD SUIT 102
-----------------------------------------------------
City | CONVERSE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-830-7464
-----------------------------------------------------
Fax | 210-830-7465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9 TROPHY RDG
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78258-7714
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-440-2132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ESHA SHAH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 213-440-2132
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------