=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841606381
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDNITE DENTAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2014
-----------------------------------------------------
Last Update Date | 04/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 E NOLANA AVE SUITE # 14
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78504-6104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-225-6675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3126
-----------------------------------------------------
City | MCALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78502-3126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-225-6675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | KLAUS JOHANN RADTKE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 415-225-6675
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 26256
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------