Basic Information
Provider Information
NPI: 1801261003
EntityType: 2
ReplacementNPI:  
OrganizationName: HALLMARK FAMILY DENTAL PA
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
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Mailing Information
Address1: 1801 PRECINCT LINE RD STE A
Address2:  
City: HURST
State: TX
PostalCode: 760543171
CountryCode: US
TelephoneNumber: 8175779200
FaxNumber:  
Practice Location
Address1: 105 BELLVUE DR
Address2:  
City: FT WORTH
State: TX
PostalCode: 761345416
CountryCode: US
TelephoneNumber: 8172932088
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/14/2015
LastUpdateDate: 12/14/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: AFKAMI
AuthorizedOfficialFirstName: KAIVAN
AuthorizedOfficialMiddleName: KEVIN
AuthorizedOfficialTitleorPosition: PRESIDENT
AuthorizedOfficialTelephone: 8175779200
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X20467TXY193400000X SINGLE SPECIALTY GROUPDental ProvidersDentist 

No ID Information.


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