MEDICARE: MRS. THERESA MARY PESCATELLO RDH

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	124Q00000X	Dental Hygienist	15033	TX

General Provider Information

NPI Number	:	1427285204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. THERESA MARY PESCATELLO RDH

Provider Business Mailing Address
First Line	:	7401 JANETTA DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76180-6744
Country	:	US
Telephone Number	:	817-240-9368
Fax Number	:

Provider Business Practice Location Address
First Line	:	6729 BRIDGE ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-0817
Country	:	US
Telephone Number	:	817-654-0354
Fax Number	:

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

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	06/18/2009

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