MEDICARE: SOUMAVA SEN, DDS, P.C.

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

General Provider Information

NPI Number	:	1992051346
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUMAVA SEN, DDS, P.C.

Provider Business Mailing Address
First Line	:	530 S MAIN ST
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4525
Country	:	US
Telephone Number	:	714-571-6481
Fax Number	:

Provider Business Practice Location Address
First Line	:	6000 CAMP BOWIE BLVD
Second Line	:	SUITE 120
City	:	FORT WORTH
State	:	TX
Zip	:	76116-5606
Country	:	US
Telephone Number	:	817-585-2475
Fax Number	:	817-585-2484

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	PEGGY M VARGAS
Credential	:
Telephone Number	:	714-571-6481

Provider Enumeration Date	:	08/02/2012
Last Update Date	:	08/02/2012

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