MEDICARE: EDWARDS RANCH DENTAL GROUP, 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	:	1417594946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EDWARDS RANCH DENTAL GROUP, PLLC

Provider Business Mailing Address
First Line	:	15660 DALLAS PKWY STE 950
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-3309
Country	:	US
Telephone Number	:	214-702-0720
Fax Number	:

Provider Business Practice Location Address
First Line	:	5701 EDWARDS RANCH RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4116
Country	:	US
Telephone Number	:	817-332-6211
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	AMANDA LIGHTFOOT
Credential	:
Telephone Number	:	214-702-0708

Provider Enumeration Date	:	12/03/2019
Last Update Date	:	01/28/2026

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