MEDICARE: ALL DENTISTRY III 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	1223G0001X	General Practice Dentistry	20159	TX

General Provider Information

NPI Number	:	1316342389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALL DENTISTRY III PLLC

Provider Business Mailing Address
First Line	:	3829 MARIGOLD AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-4944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3829 MARIGOLD AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-4944
Country	:	US
Telephone Number	:	817-759-1516
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHI T LE
Credential	:	DDS
Telephone Number	:	817-759-1516

Provider Enumeration Date	:	11/03/2014
Last Update Date	:	11/03/2014

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