MEDICARE: FAMILY DENTAL CLINIC, PC

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	12891811	TX

General Provider Information

NPI Number	:	1992137707
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY DENTAL CLINIC, PC

Provider Business Mailing Address
First Line	:	3128 FOREST LN
Second Line	:	STE. 106
City	:	DALLAS
State	:	TX
Zip	:	75234-7726
Country	:	US
Telephone Number	:	972-241-4820
Fax Number	:	972-241-1627

Provider Business Practice Location Address
First Line	:	3128 FOREST LN
Second Line	:	STE. 106
City	:	DALLAS
State	:	TX
Zip	:	75234-7726
Country	:	US
Telephone Number	:	972-241-4820
Fax Number	:	972-241-1627

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MRS. LILY B HAILEMESKEL
Credential	:
Telephone Number	:	469-939-8219

Provider Enumeration Date	:	08/02/2013
Last Update Date	:	08/02/2013

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