Healthcare Provider Details

I. General information

NPI: 1861509796
Provider Name (Legal Business Name): FOSSIL CREEK FAMILY DENTAL CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 N BEACH ST
FORT WORTH TX
76137
US

IV. Provider business mailing address

6300 N BEACH ST
FORT WORTH TX
76137
US

V. Phone/Fax

Practice location:
  • Phone: 817-281-3100
  • Fax: 817-788-5984
Mailing address:
  • Phone: 817-281-3100
  • Fax: 817-788-5984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JAMES RICHARD KING
Title or Position: DENTIST
Credential: DDS
Phone: 817-281-3100