MEDICARE: BRENT ALLEN SPEAR DDS

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	21247	TX

General Provider Information

NPI Number	:	1912054545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT ALLEN SPEAR DDS

Provider Business Mailing Address
First Line	:	4601 BYERS AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76107-4129
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4730 BOAT CLUB RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-2002
Country	:	US
Telephone Number	:	817-237-0388
Fax Number	:

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

Provider Enumeration Date	:	01/04/2007
Last Update Date	:	07/08/2007

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