MEDICARE: HOME TOWN DENTAL,PA

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	15987	TX

General Provider Information

NPI Number	:	1770790024
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOME TOWN DENTAL,PA

Provider Business Mailing Address
First Line	:	6332 LAKE WORTH BLVD
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3602
Country	:	US
Telephone Number	:	817-237-3222
Fax Number	:

Provider Business Practice Location Address
First Line	:	6332 LAKE WORTH BLVD
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3602
Country	:	US
Telephone Number	:	817-237-3222
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MONJIT S GURAM
Credential	:	DDS
Telephone Number	:	817-237-3222

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	09/12/2007

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Directions to “HOME TOWN DENTAL,PA ” Practice Location

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