Provider Demographics
NPI:1235417130
Name:AGARWAL, MONA
Entity Type:Individual
Prefix:
First Name:MONA
Middle Name:
Last Name:AGARWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5113 CEDAR BRUSH DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76123-2962
Mailing Address - Country:US
Mailing Address - Phone:423-943-1203
Mailing Address - Fax:
Practice Address - Street 1:1470 W HENDERSON ST
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-5105
Practice Address - Country:US
Practice Address - Phone:817-774-2970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2019-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX272141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice