MEDICARE: A TOOTH DOCTOR FOR KIDS DALLAS 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

General Provider Information

NPI Number	:	1962790626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A TOOTH DOCTOR FOR KIDS DALLAS PLLC

Provider Business Mailing Address
First Line	:	4550 GUS THOMASSON RD
Second Line	:
City	:	MESQUITE
State	:	TX
Zip	:	75150-1700
Country	:	US
Telephone Number	:	512-371-1222
Fax Number	:	614-462-2616

Provider Business Practice Location Address
First Line	:	3301 E THOMAS RD
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85018-7302
Country	:	US
Telephone Number	:	602-956-4411
Fax Number	:	602-956-7755

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MALCOLM RAY SCOTT JR.
Credential	:	DDS
Telephone Number	:	602-956-4411

Provider Enumeration Date	:	07/15/2011
Last Update Date	:	07/15/2011

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