Provider Demographics
NPI:1275804023
Name:J. TROY BACON DENTISTRY, PLLC
Entity Type:Organization
Organization Name:J. TROY BACON DENTISTRY, PLLC
Other - Org Name:DEL MAR DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:TROY
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-205-5140
Mailing Address - Street 1:6726 CAMP BOWIE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-7113
Mailing Address - Country:US
Mailing Address - Phone:951-205-5140
Mailing Address - Fax:
Practice Address - Street 1:6726 CAMP BOWIE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-7113
Practice Address - Country:US
Practice Address - Phone:951-205-5140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1996837Medicaid