MEDICARE: PANTEGO DENTIST, PLLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043393572	OTHER		NATIONAL PLAN AND PROVIDER ENUMERATION SYSTEM
2	1700978079	OTHER	TX	NATIONAL PLAN AND PROVIDER ENUMERATION SYSTEM

General Provider Information

NPI Number	:	1447638077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PANTEGO DENTIST, PLLC

Provider Business Mailing Address
First Line	:	301 S BOWEN RD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-1255
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	301 S BOWEN RD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76013-1255
Country	:	US
Telephone Number	:	817-339-6140
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MICHAEL STEVENS
Credential	:	D.D.S.
Telephone Number	:	281-630-2193

Provider Enumeration Date	:	05/14/2015
Last Update Date	:	05/14/2015

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