MEDICARE: CAMP BOWIE SMILES 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

General Provider Information

NPI Number	:	1518496231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMP BOWIE SMILES PLLC

Provider Business Mailing Address
First Line	:	12903 TAMARACK BEND LN
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-1569
Country	:	US
Telephone Number	:	617-771-2784
Fax Number	:

Provider Business Practice Location Address
First Line	:	9112 CAMP BOWIE WEST BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-6099
Country	:	US
Telephone Number	:	617-771-2784
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DHAVAL THAKKAR
Credential	:
Telephone Number	:	617-771-2784

Provider Enumeration Date	:	06/06/2017
Last Update Date	:	01/21/2025

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