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General NPI Number Information
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NPI Number | 1619863495
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Entity Type | Individual
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Provider Name | MINA GIRGIS DERYAS
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Gender | Male
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Dates
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Enumeration Date | 06/17/2025
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Last Update Date | 07/08/2025
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Provider Practice Location Address
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Address Line | 5925 CONVAIR DR STE 505
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City | FORT WORTH
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State | TX
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Zip | 76109-1276
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Country | US
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Telephone | 817-778-0418
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Fax |
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Provider Business Mailing Address
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Address Line | 5925 CONVAIR DR STE 505
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City | FORT WORTH
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State | TX
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Zip | 76109-1276
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 41647
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License Number State | TX
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