=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790417087
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TUMBLEWEED DENTAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2022
-----------------------------------------------------
Last Update Date | 01/19/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3625 S SONCY RD
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79119-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-351-2828
-----------------------------------------------------
Fax | 806-223-4664
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3625 S SONCY RD
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79119-6402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-351-2828
-----------------------------------------------------
Fax | 806-223-4664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE ADMINISTRATOR
-----------------------------------------------------
Name | ANGELA COVIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 806-358-2472
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------