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NPI Code Detail

MEDICARE: WESTSIDE PLASTIC SURGERY, PLLC

MEDICARE: WESTSIDE PLASTIC SURGERY, 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
1208200000XPlastic Surgery Physician

General Provider Information

NPI Number : 1730893645
Entity Type Code : Organization
Provider Name (Legal Business Name) : WESTSIDE PLASTIC SURGERY, PLLC
Provider Business Mailing Address
First Line : 3416 LOVELL AVE STE 110
Second Line :
City : FORT WORTH
State : TX
Zip : 76107-5718
Country : US
Telephone Number : 817-961-1950
Fax Number : 817-887-3105
Provider Business Practice Location Address
First Line : 3416 LOVELL AVE STE 110
Second Line :
City : FORT WORTH
State : TX
Zip : 76107-5718
Country : US
Telephone Number : 817-961-1950
Fax Number : 817-887-3105
Authorized Official
Title or Position : OFFICE MANAGER
Name : DOLORES WALLACE
Credential :
Telephone Number : 817-961-1950
Provider Enumeration Date : 01/06/2023
Last Update Date : 01/06/2023

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Directions to “WESTSIDE PLASTIC SURGERY, PLLC ” Practice Location

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