MEDICARE: FOSSIL RIDGE FAMILY 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	1223P0700X	Prosthodontics	31537	TX
2	1223G0001X	General Practice Dentistry	24625	TX

General Provider Information

NPI Number	:	1326585274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOSSIL RIDGE FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	3900 N TARRANT PKWY STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5410
Country	:	US
Telephone Number	:	817-379-9091
Fax Number	:

Provider Business Practice Location Address
First Line	:	3900 N TARRANT PKWY STE 100
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5410
Country	:	US
Telephone Number	:	817-379-9091
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KRISHNA COLLURU
Credential	:	DDS
Telephone Number	:	817-379-9091

Provider Enumeration Date	:	01/30/2017
Last Update Date	:	01/30/2017

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