MEDICARE: BIRTH FLETCHER ORAL SURGERY KELLER

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	22279	TX
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	19486	TX

General Provider Information

NPI Number	:	1053743518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRTH FLETCHER ORAL SURGERY KELLER

Provider Business Mailing Address
First Line	:	4420 HERITAGE TRACE PKWY STE 300
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8904
Country	:	US
Telephone Number	:	817-479-0541
Fax Number	:

Provider Business Practice Location Address
First Line	:	4420 HERITAGE TRACE PKWY STE 300
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8904
Country	:	US
Telephone Number	:	817-479-0541
Fax Number	:

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. CRISTI FLETCHER
Credential	:	DDS, MS
Telephone Number	:	817-479-0541

Provider Enumeration Date	:	08/06/2013
Last Update Date	:	11/04/2013

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