MEDICARE: BRIDENT DENTAL ASSOCIATES 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	122300000X	Dentist

General Provider Information

NPI Number	:	1265906143
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRIDENT DENTAL ASSOCIATES PC

Provider Business Mailing Address
First Line	:	530 S MAIN ST STE 600
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4544
Country	:	US
Telephone Number	:	714-480-3000
Fax Number	:	714-571-6445

Provider Business Practice Location Address
First Line	:	2482 JACKSBORO HWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-2201
Country	:	US
Telephone Number	:	817-626-4867
Fax Number	:	817-626-4866

Authorized Official
Title or Position	:	ENROLLMENT COORDINATOR
Name	:	MARIBEL ZAMORA
Credential	:
Telephone Number	:	714-571-3104

Provider Enumeration Date	:	01/14/2019
Last Update Date	:	01/14/2019

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