MEDICARE: DENTAL HEALTH ASSOCIATES OF TEXAS, PC

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

General Provider Information

NPI Number	:	1225589526
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL HEALTH ASSOCIATES OF TEXAS, PC

Provider Business Mailing Address
First Line	:	7200 RED HAWK CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4106
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7200 RED HAWK CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-4106
Country	:	US
Telephone Number	:	817-294-8092
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING TEAM LEAD
Name	:	HEATHER PRUEMER
Credential	:
Telephone Number	:	217-540-8434

Provider Enumeration Date	:	10/21/2016
Last Update Date	:	10/21/2016

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