Healthcare Provider Details

I. General information

NPI: 1184632754
Provider Name (Legal Business Name): FORT WORTH PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6210 JOHN RYAN DR STE 100
FORT WORTH TX
76132-4113
US

IV. Provider business mailing address

6210 JOHN RYAN DR STE 100
FORT WORTH TX
76132-4113
US

V. Phone/Fax

Practice location:
  • Phone: 817-292-5140
  • Fax:
Mailing address:
  • Phone: 817-292-5140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JANELL IRENE PLOCHECK
Title or Position: OWNER
Credential: D.D.S.
Phone: 817-292-5140