=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316383482
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIO GRANDE CITY DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2013
-----------------------------------------------------
Last Update Date | 10/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4024 E. US HIGHWAY 83 SUITE 100
-----------------------------------------------------
City | RIO GRANDE CITY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-529-8151
-----------------------------------------------------
Fax | 817-928-1681
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 E. 15TH ST. SUITE 520
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76102-6566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-529-8151
-----------------------------------------------------
Fax | 817-925-1681
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | WILLIAM HAILEY DUNKLIN
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 817-529-8151
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------