Provider Demographics
NPI:1073312302
Name:ATLANTIC DENTAL GROUP LLC
Entity type:Organization
Organization Name:ATLANTIC DENTAL GROUP LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHALED
Authorized Official - Middle Name:
Authorized Official - Last Name:TARBOUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-830-6766
Mailing Address - Street 1:3 WALDEN ELMS
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1232
Mailing Address - Country:US
Mailing Address - Phone:816-830-6766
Mailing Address - Fax:210-384-9386
Practice Address - Street 1:7519 CULEBRA RD # 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78251-1501
Practice Address - Country:US
Practice Address - Phone:816-830-6766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-10
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty