MEDICARE: PURE DENTAL SPECIALIST, 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

General Provider Information

NPI Number	:	1073144309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURE DENTAL SPECIALIST, PLLC

Provider Business Mailing Address
First Line	:	3201 W AIRPORT FWY STE 102
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062-5928
Country	:	US
Telephone Number	:	972-893-8730
Fax Number	:

Provider Business Practice Location Address
First Line	:	3829 E LOOP 820 S
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76119-4339
Country	:	US
Telephone Number	:	214-821-6468
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	FIELD HARRISON
Credential	:
Telephone Number	:	214-821-6468

Provider Enumeration Date	:	01/27/2020
Last Update Date	:	02/05/2020

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