MEDICARE: CHISHOLM TRAIL DENTAL

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	22181	TX

General Provider Information

NPI Number	:	1083044838
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHISHOLM TRAIL DENTAL

Provider Business Mailing Address
First Line	:	381 MERCEDES ST
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-2593
Country	:	US
Telephone Number	:	817-953-7700
Fax Number	:

Provider Business Practice Location Address
First Line	:	381 MERCEDES ST
Second Line	:
City	:	BENBROOK
State	:	TX
Zip	:	76126-2593
Country	:	US
Telephone Number	:	817-953-7700
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	DR. DAVID S. WHITE
Credential	:	DDS
Telephone Number	:	817-953-7700

Provider Enumeration Date	:	11/14/2013
Last Update Date	:	11/14/2013

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Directions to “CHISHOLM TRAIL DENTAL ” Practice Location

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