Healthcare Provider Details

I. General information

NPI: 1144419821
Provider Name (Legal Business Name): E M KOURI DDS MSD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2007
Last Update Date: 10/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2921 LACKLAND RD SUITE 201
FORT WORTH TX
76116-4173
US

IV. Provider business mailing address

2921 LACKLAND RD SUITE 201
FORT WORTH TX
76116-4173
US

V. Phone/Fax

Practice location:
  • Phone: 817-732-2821
  • Fax: 817-763-0419
Mailing address:
  • Phone: 817-732-2821
  • Fax: 817-763-0419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7179
License Number StateTX

VIII. Authorized Official

Name: DR. EUGENE M KOURI
Title or Position: OWNER
Credential: DDS,MSD
Phone: 817-732-2821