Healthcare Provider Details

I. General information

NPI: 1699090100
Provider Name (Legal Business Name): CHILDREN'S DENTAL SERVICES OF TEXAS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2010
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4545 BELLAIRE DR S STE 4
FORT WORTH TX
76109-1811
US

IV. Provider business mailing address

PO BOX 55367
HURST TX
76054-5367
US

V. Phone/Fax

Practice location:
  • Phone: 817-731-8600
  • Fax: 817-207-0719
Mailing address:
  • Phone: 214-533-8183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number20465
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON A ZIMMERMAN
Title or Position: OWNER
Credential: DDS
Phone: 817-731-8600