MEDICARE: MAIN DENTISTRY, P.A.

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	20290	TX

General Provider Information

NPI Number	:	1912030230
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAIN DENTISTRY, P.A.

Provider Business Mailing Address
First Line	:	4679 STATE HIGHWAY 121
Second Line	:	SUITE 109
City	:	LEWISVILLE
State	:	TX
Zip	:	75056-4010
Country	:	US
Telephone Number	:	972-370-1200
Fax Number	:	972-370-2679

Provider Business Practice Location Address
First Line	:	4679 STATE HIGHWAY 121
Second Line	:	SUITE 109
City	:	LEWISVILLE
State	:	TX
Zip	:	75056-4010
Country	:	US
Telephone Number	:	972-370-1200
Fax Number	:	972-370-2679

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. SUJATA BASAWARAJ
Credential	:	DMD
Telephone Number	:	972-370-1200

Provider Enumeration Date	:	03/14/2007
Last Update Date	:	09/24/2007

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Directions to “MAIN DENTISTRY, P.A. ” Practice Location

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