MEDICARE: DR. NACE ANTHONY FORMAGUS JR.

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	12.435	TX

General Provider Information

NPI Number	:	1124242425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NACE ANTHONY FORMAGUS JR.

Provider Business Mailing Address
First Line	:	8080 N CENTRAL EXPY
Second Line	:	380
City	:	DALLAS
State	:	TX
Zip	:	75206-1838
Country	:	US
Telephone Number	:	214-340-9179
Fax Number	:

Provider Business Practice Location Address
First Line	:	8080 N CENTRAL EXPY
Second Line	:	380
City	:	DALLAS
State	:	TX
Zip	:	75206-1838
Country	:	US
Telephone Number	:	214-340-9179
Fax Number	:

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

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	07/08/2007

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