MEDICARE: WACO KIDS DENTAL PC

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	1223P0221X	Pediatric Dentistry	22764	TX

General Provider Information

NPI Number	:	1598041659
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WACO KIDS DENTAL PC

Provider Business Mailing Address
First Line	:	1121 LAKE AIR DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-4417
Country	:	US
Telephone Number	:	254-772-8330
Fax Number	:

Provider Business Practice Location Address
First Line	:	1121 LAKE AIR DR
Second Line	:
City	:	WACO
State	:	TX
Zip	:	76710-4417
Country	:	US
Telephone Number	:	254-772-8330
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	AARON BLACKWELDER
Credential	:	DDS
Telephone Number	:	254-772-8330

Provider Enumeration Date	:	11/02/2011
Last Update Date	:	11/02/2011

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Directions to “WACO KIDS DENTAL PC ” Practice Location

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