MEDICARE: 1ST DENTAL & ORTHODONTICS

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	:	1740945260
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1ST DENTAL & ORTHODONTICS

Provider Business Mailing Address
First Line	:	5540 SYCAMORE SCHOOL RD STE 324
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3060
Country	:	US
Telephone Number	:	817-725-7500
Fax Number	:

Provider Business Practice Location Address
First Line	:	5540 SYCAMORE SCHOOL RD STE 324
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3060
Country	:	US
Telephone Number	:	817-725-7500
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	OMAR FETOUH
Credential	:	DDS
Telephone Number	:	716-348-9855

Provider Enumeration Date	:	11/01/2021
Last Update Date	:	11/01/2021

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Directions to “1ST DENTAL & ORTHODONTICS ” Practice Location

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