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NPI Code Detail

MEDICARE: WALNUT RIDGE ORTHODONTICS

MEDICARE: WALNUT RIDGE ORTHODONTICS
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
11223X0400XOrthodontics and Dentofacial Orthopedics Dentistry24724TX

General Provider Information

NPI Number : 1629331608
Entity Type Code : Organization
Provider Name (Legal Business Name) : WALNUT RIDGE ORTHODONTICS
Provider Business Mailing Address
First Line : 3807 E BROAD ST STE 101
Second Line :
City : MANSFIELD
State : TX
Zip : 76063-5623
Country : US
Telephone Number : 682-300-2300
Fax Number : 682-292-1373
Provider Business Practice Location Address
First Line : 3807 E BROAD ST STE 101
Second Line :
City : MANSFIELD
State : TX
Zip : 76063-5623
Country : US
Telephone Number : 682-300-2300
Fax Number : 682-292-1373
Authorized Official
Title or Position : ORTHODONTIST
Name : DR. STEVEN MACHICEK
Credential : D.D.S.
Telephone Number : 682-300-2300
Provider Enumeration Date : 06/24/2012
Last Update Date : 06/24/2012

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Directions to “WALNUT RIDGE ORTHODONTICS ” Practice Location

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