MEDICARE: BLUEBONNET DENTAL CARE

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	20085	TX

General Provider Information

NPI Number	:	1033496716
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEBONNET DENTAL CARE

Provider Business Mailing Address
First Line	:	3980 BOAT CLUB RD STE 114
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3206
Country	:	US
Telephone Number	:	817-237-1600
Fax Number	:	817-237-2604

Provider Business Practice Location Address
First Line	:	3980 BOAT CLUB RD STE 114
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3206
Country	:	US
Telephone Number	:	817-237-1600
Fax Number	:	817-237-2604

Authorized Official
Title or Position	:	PRESIDENT/DENTIST
Name	:	POONEH NAJAFI
Credential	:	D.D.S.
Telephone Number	:	817-237-1600

Provider Enumeration Date	:	11/09/2011
Last Update Date	:	11/09/2011

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