MEDICARE: EAST GRAND FAMILY DENTISTRY, 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	25797	TX

General Provider Information

NPI Number	:	1154760247
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST GRAND FAMILY DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	5429 E GRAND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-1914
Country	:	US
Telephone Number	:
Fax Number	:	972-239-0755

Provider Business Practice Location Address
First Line	:	5429 E GRAND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-1914
Country	:	US
Telephone Number	:	214-377-7312
Fax Number	:	214-377-7360

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SHAMIM MOSLEMI
Credential	:	D.D.S.
Telephone Number	:	972-668-3003

Provider Enumeration Date	:	06/21/2013
Last Update Date	:	11/19/2013

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