Provider Demographics
NPI:1396101010
Name:VILLAGE DDS PLLC
Entity type:Organization
Organization Name:VILLAGE DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:FETOUH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-348-9855
Mailing Address - Street 1:4041 W WHEATLAND RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75237-4063
Mailing Address - Country:US
Mailing Address - Phone:817-306-1738
Mailing Address - Fax:817-306-7366
Practice Address - Street 1:4041 W WHEATLAND RD
Practice Address - Street 2:SUITE 202
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-4063
Practice Address - Country:US
Practice Address - Phone:817-306-1738
Practice Address - Fax:817-306-7366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX303161223G0001X
TX243141223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1568871523Medicaid
TX1992950042Medicaid