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General NPI Number Information
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NPI Number | 1053743518
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Entity Type | Organization
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Legal Business Name | BIRTH FLETCHER ORAL SURGERY KELLER
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Dates
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Enumeration Date | 08/06/2013
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Last Update Date | 11/04/2013
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Provider Practice Location Address
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Address Line | 4420 HERITAGE TRACE PKWY STE 300
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City | FORT WORTH
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State | TX
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Zip | 76244-8904
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Country | US
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Telephone | 817-479-0541
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Fax |
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Provider Business Mailing Address
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Address Line | 4420 HERITAGE TRACE PKWY STE 300
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City | FORT WORTH
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State | TX
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Zip | 76244-8904
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Country | US
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Telephone | 817-479-0541
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. CRISTI FLETCHER
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Credential | DDS, MS
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Telephone | 817-479-0541
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 22279
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 19486
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License Number State | TX
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