NPIMap

Organization Active NPI

Mini Apple Dental Enterprise PLLC

  • Dentist
  • Fort Worth, TX
National Provider Identifier
1851773857
Registry record updated Jul 2, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
25064 Issued in TX
Legal business name
MINI APPLE DENTAL ENTERPRISE PLLC
Practice address
911 N Sylvania Ave
#150
Fort Worth, TX 76111
Phone
(612) 735-3712
Fax
(972) 329-7005
NPI assigned
Jun 25, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 2, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Jacob Sisombath, DDSNPI 1710154224
Title
Owner
Phone
(612) 735-3712

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X SINGLE SPECIALTY GROUP 122300000X 25064 TX Primary

Addresses

Primary practice location

911 N Sylvania Ave
#150
Fort Worth, TX 76111

Mailing address

911 N Sylvania Ave
Suite #150
Fort Worth, TX 76111-2459
Phone (612) 735-3712

Other identifiers 1

IdentifierTypeStateIssuer
25064OtherTXLICENSE

National Provider Directory

National Provider Directory

Locations

911 N Sylvania Ave
Ste 150
Fort Worth, TX 76111
Phone (612) 735-3712

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1435190400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1435795200000",
    "number": "1851773857",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "911 N SYLVANIA AVE",
            "address_2": "SUITE #150",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "761112459",
            "telephone_number": "612-735-3712",
            "fax_number": "972-329-7000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "911 N SYLVANIA AVE",
            "address_2": "#150",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "76111",
            "telephone_number": "612-735-3712",
            "fax_number": "972-329-7005"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MINI APPLE DENTAL ENTERPRISE PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-06-25",
        "last_updated": "2015-07-02",
        "status": "A",
        "authorized_official_last_name": "SISOMBATH",
        "authorized_official_first_name": "JACOB",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "612-735-3712",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "TX",
            "license": "25064",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE",
            "identifier": "25064",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Fort Worth, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 2, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.