MEDICARE: CAMP WISDOM ROAD DENTISTRY, PA

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

General Provider Information

NPI Number	:	1942515275
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMP WISDOM ROAD DENTISTRY, PA

Provider Business Mailing Address
First Line	:	PO BOX 531649
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75053-1649
Country	:	US
Telephone Number	:	972-642-2423
Fax Number	:	972-642-2571

Provider Business Practice Location Address
First Line	:	319 W CAMP WISDOM RD
Second Line	:
City	:	DUNCANVILLE
State	:	TX
Zip	:	75116-3332
Country	:	US
Telephone Number	:	972-642-2423
Fax Number	:	972-642-2571

Authorized Official
Title or Position	:	CO-PRESIDENT
Name	:	KENNETH TO
Credential	:	DDS
Telephone Number	:	972-642-2423

Provider Enumeration Date	:	08/11/2010
Last Update Date	:	06/01/2026

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