Healthcare Provider Details

I. General information

NPI: 1124277488
Provider Name (Legal Business Name): DFW PLASTIC SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W COLLEGE ST STE. 380
GRAPEVINE TX
76051-3580
US

IV. Provider business mailing address

1600 W COLLEGE ST STE. 380
GRAPEVINE TX
76051-3580
US

V. Phone/Fax

Practice location:
  • Phone: 817-481-0868
  • Fax: 817-481-1378
Mailing address:
  • Phone: 817-481-0868
  • Fax: 817-481-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG4836
License Number StateTX

VIII. Authorized Official

Name: DR. ROBERT C BLEDSOE
Title or Position: DR.
Credential: M.D.
Phone: 817-481-0868