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General NPI Number Information
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NPI Number | 1952806085
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Entity Type | Organization
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Legal Business Name | IKIDS PEDIATRIC DENTISTRY ENNIS, PLLC
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Dates
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Enumeration Date | 03/29/2018
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Last Update Date | 03/04/2021
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Provider Practice Location Address
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Address Line | 711 S CLAY ST STE A
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City | ENNIS
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State | TX
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Zip | 75119
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Country | US
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Telephone | 682-222-1010
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Fax |
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Provider Business Mailing Address
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Address Line | 2500 E BROAD ST STE 204
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City | MANSFIELD
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State | TX
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Zip | 76063-4361
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Country | US
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Telephone | 817-466-8554
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF REVENUE & CREDENTIALING
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Name | ALYSSA AGUILAR
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Credential |
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Telephone | 817-466-8554
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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