Provider Demographics
NPI:1730587304
Name:FORT WORTH EMERGENCY DENTAL CARE USA MANAGEMENT INC.
Entity type:Organization
Organization Name:FORT WORTH EMERGENCY DENTAL CARE USA MANAGEMENT INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OBENG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:402-393-2726
Mailing Address - Street 1:4245 S 143RD CIR
Mailing Address - Street 2:SUITE 7
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-4516
Mailing Address - Country:US
Mailing Address - Phone:402-393-2726
Mailing Address - Fax:
Practice Address - Street 1:5334 N TARRANT PKWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-6293
Practice Address - Country:US
Practice Address - Phone:817-581-3411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty