MEDICARE: DR. STACY VIRGIL COLE D.D.S

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	11481	TX

General Provider Information

NPI Number	:	1740643568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY VIRGIL COLE D.D.S

Provider Business Mailing Address
First Line	:	4812 BRYANT IRVIN CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-7640
Country	:	US
Telephone Number	:	817-731-9291
Fax Number	:	817-737-9767

Provider Business Practice Location Address
First Line	:	4812 BRYANT IRVIN CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-7640
Country	:	US
Telephone Number	:	817-731-9291
Fax Number	:	817-737-9767

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

Provider Enumeration Date	:	03/30/2016
Last Update Date	:	03/30/2016

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