MEDICARE: DR. JIA MING SHI 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	40871	TX

General Provider Information

NPI Number	:	1770325888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIA MING SHI DMD

Provider Business Mailing Address
First Line	:	100 E 15TH ST STE 420
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76102-6568
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1918 US-83
Second Line	:
City	:	LAREDO
State	:	TX
Zip	:	78046
Country	:	US
Telephone Number	:	956-752-9800
Fax Number	:

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

Provider Enumeration Date	:	06/10/2024
Last Update Date	:	07/31/2024

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