MEDICARE: KREATING SMILES DENTAL GROUP

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
2	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1447822309
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KREATING SMILES DENTAL GROUP

Provider Business Mailing Address
First Line	:	2921 LACKLAND RD STE 201
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-4173
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2921 LACKLAND RD STE 201
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-4173
Country	:	US
Telephone Number	:	817-732-2821
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KRISTY HONG
Credential	:	DDS
Telephone Number	:	832-677-0946

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	08/04/2021

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