Provider Demographics
NPI:1306490156
Name:FTWH DENTAL PLLC
Entity type:Organization
Organization Name:FTWH DENTAL PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUKHRAJ
Authorized Official - Middle Name:
Authorized Official - Last Name:KHASSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-753-9600
Mailing Address - Street 1:6600 NORTH FWY STE 109
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76137-7556
Mailing Address - Country:US
Mailing Address - Phone:972-679-3630
Mailing Address - Fax:
Practice Address - Street 1:6600 NORTH FWY STE 109
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-7556
Practice Address - Country:US
Practice Address - Phone:972-679-3630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty