MEDICARE: SHULTZ FAMILY DENTISTRY 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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1134779994
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHULTZ FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	4290 KINSEY DR STE 300
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-1022
Country	:	US
Telephone Number	:	903-630-6868
Fax Number	:	903-630-6871

Provider Business Practice Location Address
First Line	:	4290 KINSEY DR STE 300
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75703-1022
Country	:	US
Telephone Number	:	903-630-6868
Fax Number	:	903-630-6871

Authorized Official
Title or Position	:	OFFICER
Name	:	JARED S SHULTZ
Credential	:	DDS
Telephone Number	:	903-630-6868

Provider Enumeration Date	:	09/13/2019
Last Update Date	:	09/13/2019

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