Provider Demographics
NPI:1184632754
Name:FORT WORTH PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:FORT WORTH PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANELL
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:PLOCHECK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-292-5140
Mailing Address - Street 1:6210 JOHN RYAN DR
Mailing Address - Street 2:STE 100
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4113
Mailing Address - Country:US
Mailing Address - Phone:817-292-5140
Mailing Address - Fax:
Practice Address - Street 1:6210 JOHN RYAN DR
Practice Address - Street 2:STE 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4113
Practice Address - Country:US
Practice Address - Phone:817-292-5140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty