MEDICARE: BIRTH STEWART ORAL SURGERY FT WORTH

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	11736	TX
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	19486	TX

General Provider Information

NPI Number	:	1417389032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIRTH STEWART ORAL SURGERY FT WORTH

Provider Business Mailing Address
First Line	:	PO BOX 330874
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76163-0874
Country	:	US
Telephone Number	:	817-370-0268
Fax Number	:	817-263-9217

Provider Business Practice Location Address
First Line	:	3060 SYCAMORE SCHOOL RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76133-7771
Country	:	US
Telephone Number	:	817-370-0268
Fax Number	:	817-263-9217

Authorized Official
Title or Position	:	ORTHODONTIST
Name	:	DR. CHARLES STEWART
Credential	:	DDS
Telephone Number	:	817-370-0268

Provider Enumeration Date	:	08/06/2013
Last Update Date	:	11/08/2013

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