MEDICARE: IDEAL DENTAL OF FORT WORTH, 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	:	1437407392
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL DENTAL OF FORT WORTH, PLLC

Provider Business Mailing Address
First Line	:	12584 N BEACH ST
Second Line	:	SUITE 150
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4249
Country	:	US
Telephone Number	:	817-337-0021
Fax Number	:

Provider Business Practice Location Address
First Line	:	12584 N BEACH ST
Second Line	:	SUITE 150
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4249
Country	:	US
Telephone Number	:	817-337-0021
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RODNEY ALLES
Credential	:	DDS
Telephone Number	:	817-337-0021

Provider Enumeration Date	:	08/27/2012
Last Update Date	:	09/06/2012

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