MEDICARE: J. TROY BACON DENTISTRY, 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	122300000X	Dentist	24381	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1275804023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. TROY BACON DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	6726 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7113
Country	:	US
Telephone Number	:	951-205-5140
Fax Number	:

Provider Business Practice Location Address
First Line	:	6726 CAMP BOWIE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-7113
Country	:	US
Telephone Number	:	951-205-5140
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. JASON TROY BACON
Credential	:	D.D.S.
Telephone Number	:	951-205-5140

Provider Enumeration Date	:	01/24/2012
Last Update Date	:	01/24/2012

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