MEDICARE: FAMILY & COSMETIC DENTISTRY PC

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

General Provider Information

NPI Number	:	1447405949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY & COSMETIC DENTISTRY PC

Provider Business Mailing Address
First Line	:	2110 E RUSK ST
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-9052
Country	:	US
Telephone Number	:	903-586-0741
Fax Number	:	903-586-0649

Provider Business Practice Location Address
First Line	:	2110 E RUSK ST
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-9052
Country	:	US
Telephone Number	:	903-586-0741
Fax Number	:	903-586-0649

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LARRY L. FOLDEN
Credential	:	D.D.S
Telephone Number	:	903-586-0741

Provider Enumeration Date	:	11/25/2008
Last Update Date	:	12/19/2013

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