MEDICARE: MIKULENCAK ORTHODONTICS

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	20876	TX

General Provider Information

NPI Number	:	1912187428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIKULENCAK ORTHODONTICS

Provider Business Mailing Address
First Line	:	3208 TANGLEWOOD TRL
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-2014
Country	:	US
Telephone Number	:	817-584-0135
Fax Number	:

Provider Business Practice Location Address
First Line	:	4544 HARTWOOD DR
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1840
Country	:	US
Telephone Number	:	817-923-5400
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. DAVID MATTHEW MIKULENCAK
Credential	:	DDS, MS
Telephone Number	:	817-923-5400

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	04/07/2008

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