MEDICARE: CRAIG E KOVACH DDS INC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1417021312
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRAIG E KOVACH DDS INC

Provider Business Mailing Address
First Line	:	1243 E RED BIRD LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-2008
Country	:	US
Telephone Number	:	214-372-6062
Fax Number	:	214-372-9635

Provider Business Practice Location Address
First Line	:	1243 E RED BIRD LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-2008
Country	:	US
Telephone Number	:	214-372-6062
Fax Number	:	214-372-9635

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN MCCUISTION
Credential	:
Telephone Number	:	214-372-6062

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	08/22/2020

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