MEDICARE: RIVER OAKS FAMILY DENTAL 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	261QD0000X	Dental Clinic/Center	19032	TX

General Provider Information

NPI Number	:	1104246438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVER OAKS FAMILY DENTAL PLLC

Provider Business Mailing Address
First Line	:	901 ROBERTS CUTOFF RD
Second Line	:
City	:	RIVER OAKS
State	:	TX
Zip	:	76114-2825
Country	:	US
Telephone Number	:	817-738-4141
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 ROBERTS CUTOFF RD
Second Line	:
City	:	RIVER OAKS
State	:	TX
Zip	:	76114-2825
Country	:	US
Telephone Number	:	817-738-4141
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CHRISTOPHER ELLIOT EDMONDSON
Credential	:	D.D.S.
Telephone Number	:	817-738-4141

Provider Enumeration Date	:	04/25/2014
Last Update Date	:	04/25/2014

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