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General NPI Number Information
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NPI Number | 1972625978
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Entity Type | Organization
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Legal Business Name | PERMIAN BASIN DENTAL GROUP
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 08/08/2012
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Provider Practice Location Address
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Address Line | 2631 FAUDREE RD UNIT B
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City | ODESSA
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State | TX
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Zip | 79765-8530
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Country | US
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Telephone | 432-563-1760
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Fax | 432-563-1763
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Provider Business Mailing Address
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Address Line | 2631 FAUDREE RD UNIT B
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City | ODESSA
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State | TX
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Zip | 79765-8530
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Country | US
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Telephone | 432-563-1760
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Fax | 432-563-1763
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Authorized Official
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Title or Position | OWNER
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Name | DR. KENNETH WELBY HIGGINS
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Credential | D.D.S.
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Telephone | 432-563-1760
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12663
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License Number State | TX
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