MEDICARE: MAIN STREET DOWNTOWN DENTAL 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
1	122300000X	Dentist	22768	TX
2	122300000X	Dentist	23850	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851721922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN STREET DOWNTOWN DENTAL PLLC

Provider Business Mailing Address
First Line	:	207 E 6TH ST
Second Line	:
City	:	BONHAM
State	:	TX
Zip	:	75418-3729
Country	:	US
Telephone Number	:	469-734-7942
Fax Number	:

Provider Business Practice Location Address
First Line	:	226 MAIN ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-2707
Country	:	US
Telephone Number	:	469-734-7942
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	DR. KAJURI RAMCHAND
Credential	:	DDS
Telephone Number	:	469-734-7942

Provider Enumeration Date	:	11/26/2013
Last Update Date	:	12/03/2013

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