MEDICARE: FORT WORTH EMERGENCY DENTAL CARE USA MANAGEMENT INC.

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

General Provider Information

NPI Number	:	1730587304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH EMERGENCY DENTAL CARE USA MANAGEMENT INC.

Provider Business Mailing Address
First Line	:	4245 S 143RD CIR
Second Line	:	SUITE 7
City	:	OMAHA
State	:	NE
Zip	:	68137-4516
Country	:	US
Telephone Number	:	402-393-2726
Fax Number	:

Provider Business Practice Location Address
First Line	:	5334 N TARRANT PKWY
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-6293
Country	:	US
Telephone Number	:	817-581-3411
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MICHAEL OBENG
Credential	:
Telephone Number	:	402-393-2726

Provider Enumeration Date	:	12/15/2014
Last Update Date	:	12/15/2014

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