Provider Demographics
NPI:1972625978
Name:PERMIAN BASIN DENTAL GROUP
Entity type:Organization
Organization Name:PERMIAN BASIN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WELBY
Authorized Official - Last Name:HIGGINS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:432-563-1760
Mailing Address - Street 1:2631 FAUDREE RD UNIT B
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79765-8530
Mailing Address - Country:US
Mailing Address - Phone:432-563-1760
Mailing Address - Fax:432-563-1763
Practice Address - Street 1:2631 FAUDREE RD UNIT B
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79765-8530
Practice Address - Country:US
Practice Address - Phone:432-563-1760
Practice Address - Fax:432-563-1763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12663122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX177458001Medicaid