Provider Demographics
NPI:1164602520
Name:SHRESTHA, DAZZLE B (DC)
Entity Type:Individual
Prefix:DR
First Name:DAZZLE
Middle Name:B
Last Name:SHRESTHA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 W MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4612
Mailing Address - Country:US
Mailing Address - Phone:817-924-1444
Mailing Address - Fax:
Practice Address - Street 1:813 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4612
Practice Address - Country:US
Practice Address - Phone:817-924-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor