MEDICARE: GLENN TRAUTMANN DMD

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	1223E0200X	Endodontics	20012	TX

General Provider Information

NPI Number	:	1992896294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN TRAUTMANN DMD

Provider Business Mailing Address
First Line	:	1530 BLUE FOREST DR
Second Line	:
City	:	PROSPER
State	:	TX
Zip	:	75078-9382
Country	:	US
Telephone Number	:	972-347-9865
Fax Number	:	972-347-9865

Provider Business Practice Location Address
First Line	:	1100 AIRPORT FWY
Second Line	:	SUITE 105
City	:	BEDFORD
State	:	TX
Zip	:	76022-6667
Country	:	US
Telephone Number	:	817-267-3966
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	07/08/2007

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