MEDICARE: DR. STEPHEN GATLIN BROGDON DDS

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	17178	TX

General Provider Information

NPI Number	:	1194835215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN GATLIN BROGDON DDS

Provider Business Mailing Address
First Line	:	3646 GRANBURY RD
Second Line	:	SUITE 104
City	:	FORT WORTH
State	:	TX
Zip	:	76109-3717
Country	:	US
Telephone Number	:	817-923-4606
Fax Number	:	817-923-5593

Provider Business Practice Location Address
First Line	:	3646 GRANBURY RD
Second Line	:	SUITE 104
City	:	FORT WORTH
State	:	TX
Zip	:	76109-3717
Country	:	US
Telephone Number	:	817-923-4606
Fax Number	:	817-923-5593

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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