MEDICARE: SD MEADOWBROOK PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1023707106
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SD MEADOWBROOK PLLC

Provider Business Mailing Address
First Line	:	PO BOX 453247
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75045-3247
Country	:	US
Telephone Number	:	817-466-0800
Fax Number	:

Provider Business Practice Location Address
First Line	:	6302 MEADOWBROOK DR STE 112
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-5163
Country	:	US
Telephone Number	:	817-466-0800
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LYNHTHY T. PHAM
Credential	:	DDS
Telephone Number	:	469-902-6792

Provider Enumeration Date	:	05/03/2023
Last Update Date	:	05/03/2023

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