MEDICARE: MUSIC CITY MALL DENTAL PRACTICE, P.C.

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	:	1265737910
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MUSIC CITY MALL DENTAL PRACTICE, P.C.

Provider Business Mailing Address
First Line	:	4101 E 42ND ST # B-23
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79762-7239
Country	:	US
Telephone Number	:	432-363-4867
Fax Number	:	432-363-1799

Provider Business Practice Location Address
First Line	:	4101 E 42ND ST # B-23
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79762-7239
Country	:	US
Telephone Number	:	432-363-4867
Fax Number	:	432-363-1799

Authorized Official
Title or Position	:	MANAGER
Name	:	JENNIFER OWENS
Credential	:
Telephone Number	:	432-520-4867

Provider Enumeration Date	:	01/11/2011
Last Update Date	:	01/11/2011

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