MEDICARE: FULL SMILE PERIODONTICS, 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	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1083359368
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULL SMILE PERIODONTICS, PLLC

Provider Business Mailing Address
First Line	:	5051 S SONCY RD
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79119-6667
Country	:	US
Telephone Number	:	806-353-1055
Fax Number	:	806-353-7077

Provider Business Practice Location Address
First Line	:	4515 VAN WINKLE DR
Second Line	:
City	:	AMARILLO
State	:	TX
Zip	:	79119-6423
Country	:	US
Telephone Number	:	806-699-6111
Fax Number	:	806-353-7077

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM E GRAVES
Credential	:	DMD
Telephone Number	:	806-353-1055

Provider Enumeration Date	:	05/02/2022
Last Update Date	:	06/03/2022

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