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General NPI Number Information
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NPI Number | 1053769356
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Entity Type | Organization
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Legal Business Name | MY TEETH DENTAL ORTHODONTICS PLLC
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Dates
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Enumeration Date | 05/26/2016
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Last Update Date | 04/15/2017
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Provider Practice Location Address
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Address Line | 2063 TOWN EAST MALL STE 1036
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City | MESQUITE
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State | TX
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Zip | 75150-4118
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Country | US
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Telephone | 716-348-9855
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Fax |
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Provider Business Mailing Address
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Address Line | 2063 TOWN EAST MALL STE 1036
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City | MESQUITE
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State | TX
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Zip | 75150-4118
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Country | US
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Telephone | 716-348-9855
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | OMAR FETOUH
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Credential |
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Telephone | 716-348-9855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 24314
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License Number State | TX
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