MEDICARE: ALTAMESA DENTAL HOME 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26309	OTHER	TX	DENTAL LIC

General Provider Information

NPI Number	:	1174116974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALTAMESA DENTAL HOME PLLC

Provider Business Mailing Address
First Line	:	2101 ALTAMESA BLVD # 103
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-3328
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2101 ALTAMESA BLVD # 103
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76134-3328
Country	:	US
Telephone Number	:	423-946-9375
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. ROHIT NARAYAN
Credential	:	DDS
Telephone Number	:	423-946-9375

Provider Enumeration Date	:	02/12/2021
Last Update Date	:	02/12/2021

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