MEDICARE: DAZZLE DENTAL CARE, PA

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	122300000X	Dentist	22585	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043479066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAZZLE DENTAL CARE, PA

Provider Business Mailing Address
First Line	:	1121 FLOWER MOUND RD
Second Line	:	SUITE 500
City	:	FLOWER MOUND
State	:	TX
Zip	:	75028-3504
Country	:	US
Telephone Number	:	972-355-8568
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 FLOWER MOUND RD
Second Line	:	SUITE 500
City	:	FLOWER MOUND
State	:	TX
Zip	:	75028-3504
Country	:	US
Telephone Number	:	972-355-8568
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/ DENTIST
Name	:	DR. JOHNIE M NGUYEN
Credential	:	DDS
Telephone Number	:	972-355-8568

Provider Enumeration Date	:	06/05/2008
Last Update Date	:	04/25/2011

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Directions to “DAZZLE DENTAL CARE, PA ” Practice Location

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