MEDICARE: SMILE WORKSHOP 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	122300000X	Dentist

General Provider Information

NPI Number	:	1700295557
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE WORKSHOP FORT WORTH, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 840925
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-0925
Country	:	US
Telephone Number	:	214-757-4500
Fax Number	:	214-757-4501

Provider Business Practice Location Address
First Line	:	7355 N BEACH ST
Second Line	:	SUITE 1344
City	:	FORT WORTH
State	:	TX
Zip	:	76137-1897
Country	:	US
Telephone Number	:	817-935-8686
Fax Number	:	682-253-1885

Authorized Official
Title or Position	:	OWNER
Name	:	SULMAN AHMED
Credential	:	DMD
Telephone Number	:	972-331-8079

Provider Enumeration Date	:	08/06/2014
Last Update Date	:	08/15/2023

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