MEDICARE: DR. ALEXANDER KAMRAN MOLAYEM DDS

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	24716	TX
2	1223G0001X	General Practice Dentistry	P65190	NY

General Provider Information

NPI Number	:	1568611275
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALEXANDER KAMRAN MOLAYEM DDS

Provider Business Mailing Address
First Line	:	4731 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3835
Country	:	US
Telephone Number	:	817-531-0431
Fax Number	:	817-531-2389

Provider Business Practice Location Address
First Line	:	4731 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3835
Country	:	US
Telephone Number	:	817-531-0431
Fax Number	:	817-531-2389

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

Provider Enumeration Date	:	09/17/2008
Last Update Date	:	10/14/2010

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