MEDICARE: DR. MONJIT S GURAM DDS

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	15987	TX

General Provider Information

NPI Number	:	1770594848
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MONJIT S GURAM DDS

Provider Business Mailing Address
First Line	:	3825 YUCCA AVE STE 121
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76111-6067
Country	:	US
Telephone Number	:	817-927-8500
Fax Number	:	817-927-8508

Provider Business Practice Location Address
First Line	:	3825 YUCCA AVE
Second Line	:	SUITE 121
City	:	FORT WORTH
State	:	TX
Zip	:	76111-6067
Country	:	US
Telephone Number	:	817-927-8500
Fax Number	:	817-927-8508

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	05/10/2012

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