Healthcare Provider Details

I. General information

NPI: 1639144140
Provider Name (Legal Business Name): BEHZAD BAGHAI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2006
Last Update Date: 10/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3204 N MAIN ST # 121
FORT WORTH TX
76106-5900
US

IV. Provider business mailing address

3204 N MAIN ST # 121
FORT WORTH TX
76106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 817-624-6677
  • Fax: 817-624-6678
Mailing address:
  • Phone: 817-624-6677
  • Fax: 817-624-6678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number0401411093
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number23664
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: