1417389032 NPI number — BIRTH STEWART ORAL SURGERY FT WORTH

Table of content: (NPI 1417389032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417389032 NPI number — BIRTH STEWART ORAL SURGERY FT WORTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BIRTH STEWART ORAL SURGERY FT WORTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417389032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 330874
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76163-0874
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-370-0268
Provider Business Mailing Address Fax Number:
817-263-9217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3060 SYCAMORE SCHOOL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76133-7771
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-370-0268
Provider Business Practice Location Address Fax Number:
817-263-9217
Provider Enumeration Date:
08/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
STEWART
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
Authorized Official Title or Position:
ORTHODONTIST
Authorized Official Telephone Number:
817-370-0268

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  19486 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223S0112X , with the licence number: 11736 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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