MEDICARE: TARRANT DENTAL GROUP PLLC

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

General Provider Information

NPI Number	:	1679207641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TARRANT DENTAL GROUP PLLC

Provider Business Mailing Address
First Line	:	5000 LEGACY DR STE 240
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-3112
Country	:	US
Telephone Number	:	646-662-3105
Fax Number	:

Provider Business Practice Location Address
First Line	:	5310 N TARRANT PKWY STE 104
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-5386
Country	:	US
Telephone Number	:	817-849-9777
Fax Number	:	817-887-2722

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	ANDREW XU
Credential	:	DDS
Telephone Number	:	646-662-3105

Provider Enumeration Date	:	07/14/2022
Last Update Date	:	07/20/2022

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