MEDICARE: MINT DENTISTRY, 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	23874	TX

General Provider Information

NPI Number	:	1770823593
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MINT DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	3201 W AIRPORT FREEWAY STE 102
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75062
Country	:	US
Telephone Number	:	972-893-8730
Fax Number	:	469-619-6941

Provider Business Practice Location Address
First Line	:	105 E BELT LINE RD
Second Line	:	STE 900
City	:	CEDAR HILL
State	:	TX
Zip	:	75104-2201
Country	:	US
Telephone Number	:	214-821-6468
Fax Number	:	972-293-1007

Authorized Official
Title or Position	:	CEO
Name	:	FIELD HARRISON
Credential	:	DDS
Telephone Number	:	214-821-6468

Provider Enumeration Date	:	02/15/2013
Last Update Date	:	01/29/2019

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