MEDICARE: DR. COURTNEY MICHEL FAVALORO DDS

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223P0221X	Pediatric Dentistry	40999	TX

General Provider Information

NPI Number	:	1396491320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. COURTNEY MICHEL FAVALORO DDS

Provider Business Mailing Address
First Line	:	5841 ORAM ST UNIT 3
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75206-7229
Country	:	US
Telephone Number	:	713-829-2337
Fax Number	:

Provider Business Practice Location Address
First Line	:	9757 WHITE ROCK TRL
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75238-1805
Country	:	US
Telephone Number	:	214-349-9400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2022
Last Update Date	:	10/02/2024

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