MEDICARE: DR. MITA DESAI DDS

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	21968	TX
2	1223G0001X	General Practice Dentistry	21968	TX

General Provider Information

NPI Number	:	1770573594
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MITA DESAI DDS

Provider Business Mailing Address
First Line	:	4763 BARWICK DR STE 106
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1531
Country	:	US
Telephone Number	:	817-926-5485
Fax Number	:	817-924-0014

Provider Business Practice Location Address
First Line	:	4763 BARWICK DR STE 106
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1531
Country	:	US
Telephone Number	:	817-926-5485
Fax Number	:	817-924-0014

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2005
Last Update Date	:	06/11/2019

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