MEDICARE: EVANGELISTA DENTAL CARE, 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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841591658
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVANGELISTA DENTAL CARE, PLLC

Provider Business Mailing Address
First Line	:	6600 NORTH FWY STE 109
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-7556
Country	:	US
Telephone Number	:	817-232-4600
Fax Number	:	817-232-4610

Provider Business Practice Location Address
First Line	:	6600 NORTH FWY STE 109
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76137-7556
Country	:	US
Telephone Number	:	817-232-4600
Fax Number	:	817-232-4610

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. EDWINA JIMENEZ EVANGELISTA
Credential	:	DDS
Telephone Number	:	817-232-4600

Provider Enumeration Date	:	11/10/2010
Last Update Date	:	11/10/2010

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