MEDICARE: TIMBER CREEK DENTAL & ORTHODONTICS

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	19907	TX

General Provider Information

NPI Number	:	1437684354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIMBER CREEK DENTAL & ORTHODONTICS

Provider Business Mailing Address
First Line	:	12650 N BEACH ST
Second Line	:	SUITE 100
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4243
Country	:	US
Telephone Number	:	817-562-3292
Fax Number	:	817-337-9375

Provider Business Practice Location Address
First Line	:	12650 N BEACH ST
Second Line	:	SUITE 100
City	:	FORT WORTH
State	:	TX
Zip	:	76244-4243
Country	:	US
Telephone Number	:	817-562-3292
Fax Number	:	817-337-9375

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. TIMOTHY CASEY
Credential	:	DDS
Telephone Number	:	817-562-3292

Provider Enumeration Date	:	04/28/2017
Last Update Date	:	04/28/2017

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