Provider Demographics
NPI:1366777625
Name:NTKC-DFW, PLLC
Entity type:Organization
Organization Name:NTKC-DFW, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BACCUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-488-6669
Mailing Address - Street 1:3801 WILLIAM D TATE AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-8755
Mailing Address - Country:US
Mailing Address - Phone:817-488-6812
Mailing Address - Fax:817-251-1303
Practice Address - Street 1:805 HILL BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1481
Practice Address - Country:US
Practice Address - Phone:817-294-0280
Practice Address - Fax:817-294-2084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208809801Medicaid
TX208809801Medicaid