MEDICARE: HOME TOWN DENTAL OF FORT WORTH PC

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	:	1447405139
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME TOWN DENTAL OF FORT WORTH PC

Provider Business Mailing Address
First Line	:	3515 SYCAMORE SCHOOL RD STE 170
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-7823
Country	:	US
Telephone Number	:	817-927-8500
Fax Number	:	817-927-8508

Provider Business Practice Location Address
First Line	:	3515 SYCAMORE SCHOOL RD STE 170
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-7823
Country	:	US
Telephone Number	:	817-927-8500
Fax Number	:	817-927-8508

Authorized Official
Title or Position	:	REGIONAL MANAGER
Name	:	MRS. PATTY SANCHEZ
Credential	:
Telephone Number	:	817-927-8500

Provider Enumeration Date	:	11/21/2008
Last Update Date	:	11/21/2008

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