MEDICARE: ORAL SLEEP APPLIANCES LLC

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	332BC3200X	Customized Equipment (DME)	15778	TX

General Provider Information

NPI Number	:	1982077152
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORAL SLEEP APPLIANCES LLC

Provider Business Mailing Address
First Line	:	4750 BRYANT IRVIN RD
Second Line	:	823
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3633
Country	:	US
Telephone Number	:	817-441-2674
Fax Number	:	817-441-2694

Provider Business Practice Location Address
First Line	:	4750 BRYANT IRVIN RD
Second Line	:	823
City	:	FORT WORTH
State	:	TX
Zip	:	76132-3633
Country	:	US
Telephone Number	:	817-441-2674
Fax Number	:	817-441-2694

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RONALD LEON COOK
Credential	:	D.D.S.
Telephone Number	:	817-441-2674

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	11/10/2015

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