MEDICARE: HAPPY TEETH DENTAL CENTERS

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	24716	TX

General Provider Information

NPI Number	:	1841503877
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAPPY TEETH DENTAL CENTERS

Provider Business Mailing Address
First Line	:	4731 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3835
Country	:	US
Telephone Number	:	817-496-0400
Fax Number	:	817-887-4600

Provider Business Practice Location Address
First Line	:	4731 E LANCASTER AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76103-3835
Country	:	US
Telephone Number	:	817-496-0400
Fax Number	:	817-887-4600

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	PRISCILLA DUARTE
Credential	:	CMOM
Telephone Number	:	214-549-2273

Provider Enumeration Date	:	07/19/2010
Last Update Date	:	07/19/2010

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