MEDICARE: DFW CROWN DENTAL OF SOUTH LANCASTER 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	1223G0001X	General Practice Dentistry	24534	TX

General Provider Information

NPI Number	:	1700105848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DFW CROWN DENTAL OF SOUTH LANCASTER PC

Provider Business Mailing Address
First Line	:	5319 RIVER LAKE WAY
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75052-0713
Country	:	US
Telephone Number	:	817-793-8102
Fax Number	:

Provider Business Practice Location Address
First Line	:	2729 S LANCASTER RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75216-3114
Country	:	US
Telephone Number	:	214-371-3131
Fax Number	:	214-371-3140

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. TU KIM NGUYEN
Credential	:	DDS
Telephone Number	:	817-793-8102

Provider Enumeration Date	:	05/28/2010
Last Update Date	:	08/20/2010

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