MEDICARE: LAURA WASEK-THROM DMD,MPH

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	2901021520	MI
2	1223G0001X	General Practice Dentistry	35880	TX

General Provider Information

NPI Number	:	1881144236
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA WASEK-THROM DMD,MPH

Provider Business Mailing Address
First Line	:	4225 RANIER CT
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-5028
Country	:	US
Telephone Number	:	231-392-3553
Fax Number	:

Provider Business Practice Location Address
First Line	:	5720 LOCKE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-5020
Country	:	US
Telephone Number	:	817-737-6601
Fax Number	:

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

Provider Enumeration Date	:	10/10/2016
Last Update Date	:	10/18/2022

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