MEDICARE: STEVEN FOSSUM DDS

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	22804	TX

General Provider Information

NPI Number	:	1043398365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEVEN FOSSUM DDS

Provider Business Mailing Address
First Line	:	201 E CEN TEX EXPY
Second Line	:	#500
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-1887
Country	:	US
Telephone Number	:	713-443-0984
Fax Number	:	254-690-1506

Provider Business Practice Location Address
First Line	:	201 E CEN TEX EXPY
Second Line	:	#500
City	:	HARKER HEIGHTS
State	:	TX
Zip	:	76548-1887
Country	:	US
Telephone Number	:	713-443-0984
Fax Number	:	254-690-1506

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	02/03/2009

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