MEDICARE: ABC123 DENTAL IN HALTOM 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	24570	TX

General Provider Information

NPI Number	:	1740569144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABC123 DENTAL IN HALTOM PLLC

Provider Business Mailing Address
First Line	:	5416 BASSWOOD BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-4400
Country	:	US
Telephone Number	:	817-656-1215
Fax Number	:	877-687-6861

Provider Business Practice Location Address
First Line	:	5416 BASSWOOD BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-4400
Country	:	US
Telephone Number	:	817-656-1215
Fax Number	:	877-687-6861

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. TRI H PHAM
Credential	:	DDS
Telephone Number	:	817-656-1215

Provider Enumeration Date	:	08/16/2011
Last Update Date	:	08/16/2011

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