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General NPI Number Information
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NPI Number | 1104939024
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Entity Type | Organization
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Legal Business Name | FORT WORTH DENTAL
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Dates
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Enumeration Date | 08/16/2006
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Last Update Date | 10/11/2012
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Provider Practice Location Address
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Address Line | 4620 CITYLAKE BLVD W
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City | FORT WORTH
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State | TX
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Zip | 76132-3695
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Country | US
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Telephone | 817-263-0202
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Fax | 817-927-7197
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Provider Business Mailing Address
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Address Line | 4620 CITYLAKE BLVD W
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City | FORT WORTH
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State | TX
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Zip | 76132-3695
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Country | US
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Telephone | 817-263-0202
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Fax | 817-927-7197
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Authorized Official
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Title or Position | OWNER
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Name | DR. ARTHUR JACKSON MUND III
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Credential | D.D.S.
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Telephone | 817-263-0202
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 13209
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License Number State | TX
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