MEDICARE: PECAN TREE DENTAL

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	122300000X	Dentist	26362	TX

General Provider Information

NPI Number	:	1639512403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PECAN TREE DENTAL

Provider Business Mailing Address
First Line	:	775 W WESTCHESTER PKWY
Second Line	:	#101
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-2856
Country	:	US
Telephone Number	:	972-262-5111
Fax Number	:	972-262-6812

Provider Business Practice Location Address
First Line	:	775 W WESTCHESTER PKWY
Second Line	:	#101
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-2856
Country	:	US
Telephone Number	:	972-262-5111
Fax Number	:	972-262-6812

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. QUINN J SMITH
Credential	:	DDS
Telephone Number	:	972-262-5111

Provider Enumeration Date	:	04/11/2013
Last Update Date	:	04/11/2013

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Directions to “PECAN TREE DENTAL ” Practice Location

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