MEDICARE: ACD PROFESSIONAL

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	:	1295162345
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACD PROFESSIONAL

Provider Business Mailing Address
First Line	:	1127 S MAIN ST
Second Line	:
City	:	GRAPEVINE
State	:	TX
Zip	:	76051-7533
Country	:	US
Telephone Number	:	817-380-5936
Fax Number	:	817-442-0900

Provider Business Practice Location Address
First Line	:	2700 BARTON CREEK BLVD
Second Line	:	STE 100
City	:	AUSTIN
State	:	TX
Zip	:	78735-1641
Country	:	US
Telephone Number	:	512-382-5888
Fax Number	:	512-382-5826

Authorized Official
Title or Position	:	DENTIST
Name	:	JARED BRUGGEMAN
Credential	:	DDS
Telephone Number	:	817-912-2982

Provider Enumeration Date	:	10/03/2013
Last Update Date	:	10/03/2013

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