MEDICARE: VILLAGE PERIODONTICS & IMPLANT DENT

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	1223P0300X	Periodontics	16373	TX

General Provider Information

NPI Number	:	1649768979
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE PERIODONTICS & IMPLANT DENT

Provider Business Mailing Address
First Line	:	2820 VILLAGE PKWY STE 630
Second Line	:
City	:	HIGHLAND VILLAGE
State	:	TX
Zip	:	75077-3299
Country	:	US
Telephone Number	:	972-966-2500
Fax Number	:	972-471-9833

Provider Business Practice Location Address
First Line	:	2820 VILLAGE PKWY STE 630
Second Line	:
City	:	HIGHLAND VILLAGE
State	:	TX
Zip	:	75077-3299
Country	:	US
Telephone Number	:	972-966-2500
Fax Number	:	972-471-9833

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JANE C MOORE
Credential	:
Telephone Number	:	972-966-2500

Provider Enumeration Date	:	04/23/2018
Last Update Date	:	04/23/2018

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Directions to “VILLAGE PERIODONTICS & IMPLANT DENT ” Practice Location

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