MEDICARE: JANE POQUIZ

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	19111	TX

General Provider Information

NPI Number	:	1316005994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE POQUIZ

Provider Business Mailing Address
First Line	:	650 INTERNATIONAL PKWY
Second Line	:	SUITE 100
City	:	RICHARDSON
State	:	TX
Zip	:	75081-6612
Country	:	US
Telephone Number	:	817-246-9040
Fax Number	:

Provider Business Practice Location Address
First Line	:	6261 OLD GRANBURY RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-3401
Country	:	US
Telephone Number	:	817-246-9040
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2006
Last Update Date	:	07/08/2007

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