MEDICARE: DR. CARL DOUGLAS FOSTER D.D.S.

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	1223D0001X	Public Health Dentistry	11802	TX
2	122300000X	Dentist	11802	TX

General Provider Information

NPI Number	:	1487657011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARL DOUGLAS FOSTER D.D.S.

Provider Business Mailing Address
First Line	:	222 S. CAMPBELL ST.
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79901-2838
Country	:	US
Telephone Number	:	915-543-3580
Fax Number	:	915-543-3510

Provider Business Practice Location Address
First Line	:	9314 JUANCITIDO LANE
Second Line	:	YSLETA DEL SUR PUEBLO COMMUNITY HEALTH CENTER
City	:	EL PASO
State	:	TX
Zip	:	79907
Country	:	US
Telephone Number	:	915-858-1076
Fax Number	:	915-858-2367

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

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	09/05/2008

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