MEDICARE: FORT WORTH DENTAL CARE PLLC

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	261QD0000X	Dental Clinic/Center	17178	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1194835215	OTHER		NPI

General Provider Information

NPI Number	:	1972001048
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORT WORTH DENTAL CARE PLLC

Provider Business Mailing Address
First Line	:	3646 GRANBURY RD # 104
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-3717
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3646 GRANBURY RD # 104
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-3717
Country	:	US
Telephone Number	:	817-923-4606
Fax Number	:	817-923-5593

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STEPHEN GATLIN BROGDON
Credential	:	DDS
Telephone Number	:	817-923-4606

Provider Enumeration Date	:	01/24/2018
Last Update Date	:	01/24/2018

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