MEDICARE: MICHAELANGELO DENTISTRY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	23341	TX

General Provider Information

NPI Number	:	1013230705
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAELANGELO DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	2417 PARK HILL DR # 119
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-2240
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2417 PARK HILL DR # 119
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-2240
Country	:	US
Telephone Number	:	817-926-9771
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHAEL COLANGELO
Credential	:	DDS
Telephone Number	:	817-689-4284

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	03/09/2010

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