MEDICARE: ODESSA MALL FDC 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	122300000X	Dentist	0008481	TX

General Provider Information

NPI Number	:	1801054044
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ODESSA MALL FDC PA

Provider Business Mailing Address
First Line	:	4101 E 42ND
Second Line	:	STE B23
City	:	ODESSA
State	:	TX
Zip	:	79762-7239
Country	:	US
Telephone Number	:	432-363-4867
Fax Number	:	432-363-1799

Provider Business Practice Location Address
First Line	:	4101 E 42ND
Second Line	:	STE B23
City	:	ODESSA
State	:	TX
Zip	:	79762-7239
Country	:	US
Telephone Number	:	432-363-4867
Fax Number	:	432-363-1799

Authorized Official
Title or Position	:	REGIONAL MANAGER
Name	:	LYNN ARMSTRONG
Credential	:
Telephone Number	:	505-328-4867

Provider Enumeration Date	:	05/23/2008
Last Update Date	:	05/23/2008

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Directions to “ODESSA MALL FDC PA ” Practice Location

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