Provider Demographics
NPI:1386979649
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 1:2425 HIGHWAY 121 STE 201
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5011
Practice Address - Country:US
Practice Address - Phone:817-283-5166
Practice Address - Fax:817-283-5176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-05
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209283502Medicaid
TX209283502Medicaid