MEDICARE: JACKSBORO SMILES BY WIRE, 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1528211406
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSBORO SMILES BY WIRE, PLLC

Provider Business Mailing Address
First Line	:	4901 LBJ FREEWAY
Second Line	:	SUITE 400
City	:	DALLAS
State	:	TX
Zip	:	75244-6158
Country	:	US
Telephone Number	:	214-342-5757
Fax Number	:	214-389-5844

Provider Business Practice Location Address
First Line	:	2480 JACKSBORO HWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76114-2201
Country	:	US
Telephone Number	:	817-529-0994
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ADRIAN CODEL
Credential	:	DDS
Telephone Number	:	214-342-5757

Provider Enumeration Date	:	10/23/2008
Last Update Date	:	02/16/2011

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