MEDICARE: ACCESS DENTAL OF MEADOWBROOK

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

General Provider Information

NPI Number	:	1770729386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACCESS DENTAL OF MEADOWBROOK

Provider Business Mailing Address
First Line	:	6302 MEADOWBROOK DR
Second Line	:	SUITE #112
City	:	FORT WORTH
State	:	TX
Zip	:	76112-5121
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6302 MEADOWBROOK DR
Second Line	:	SUITE #112
City	:	FORT WORTH
State	:	TX
Zip	:	76112-5121
Country	:	US
Telephone Number	:	214-678-9200
Fax Number	:

Authorized Official
Title or Position	:	VP
Name	:	TIEN DINH PHAN
Credential	:	DMD
Telephone Number	:	214-678-9200

Provider Enumeration Date	:	01/02/2009
Last Update Date	:	01/02/2009

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