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General NPI Number Information
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NPI Number | 1396988150
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Entity Type | Organization
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Legal Business Name | MIMI FAMILY DENTAL
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Dates
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Enumeration Date | 04/09/2009
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Last Update Date | 04/09/2009
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Provider Practice Location Address
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Address Line | 1200 OVERLOOK TER SUITE C
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City | FORT WORTH
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State | TX
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Zip | 76112-2382
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Country | US
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Telephone | 817-451-8855
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Fax | 817-457-8860
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Provider Business Mailing Address
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Address Line | 1200 OVERLOOK TER SUITE C
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City | FORT WORTH
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State | TX
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Zip | 76112-2382
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Country | US
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Telephone | 817-451-8855
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Fax | 817-457-8860
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. LEE LANG
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Credential |
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Telephone | 817-451-8855
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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 |
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License Number State |
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