MEDICARE: CHANDLER BULLOCK DMD

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	34288	TX

General Provider Information

NPI Number	:	1730662040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHANDLER BULLOCK DMD

Provider Business Mailing Address
First Line	:	6217 OAKMONT BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2812
Country	:	US
Telephone Number	:	682-224-1464
Fax Number	:

Provider Business Practice Location Address
First Line	:	6217 OAKMONT BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-2812
Country	:	US
Telephone Number	:	682-224-1464
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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Directions to “ CHANDLER BULLOCK DMD” Practice Location

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