Provider Demographics
NPI:1528476991
Name:FORT WORTH COSMETIC & FAMILY DENTISTRY
Entity type:Organization
Organization Name:FORT WORTH COSMETIC & FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERE
Authorized Official - Middle Name:SIERRA
Authorized Official - Last Name:REDD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-737-6601
Mailing Address - Street 1:5720 LOCKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107
Mailing Address - Country:US
Mailing Address - Phone:817-737-6601
Mailing Address - Fax:817-737-6446
Practice Address - Street 1:5720 LOCKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107
Practice Address - Country:US
Practice Address - Phone:817-737-6601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty