MEDICARE: LAURA KLEIN D.D.S.

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	122300000X	Dentist	29987	TX

General Provider Information

NPI Number	:	1073926143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA KLEIN D.D.S.

Provider Business Mailing Address
First Line	:	2551 RIVER PARK PLZ
Second Line	:	SUITE 210
City	:	FORT WORTH
State	:	TX
Zip	:	76116-0689
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2551 RIVER PARK PLZ
Second Line	:	SUITE 210
City	:	FORT WORTH
State	:	TX
Zip	:	76116-0689
Country	:	US
Telephone Number	:	817-732-4419
Fax Number	:

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

Provider Enumeration Date	:	06/06/2014
Last Update Date	:	09/13/2016

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