=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619427002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOW FAMILY DENTAL P.A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2016
-----------------------------------------------------
Last Update Date | 10/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3306 W CAMP WISDOM RD STE. 100
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75237-2596
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-577-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 PRECINCT LINE RD STE. A
-----------------------------------------------------
City | HURST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76054-3170
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-577-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KAIVAN AFKAMI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 817-577-9200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 20467
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------