Provider Demographics
NPI:1508805516
Name:CECERE, JOSEPH CARL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:CARL
Last Name:CECERE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2501 RIDGMAR PLZ
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-2689
Mailing Address - Country:US
Mailing Address - Phone:817-731-8629
Mailing Address - Fax:817-732-0563
Practice Address - Street 1:2501 RIDGMAR PLZ
Practice Address - Street 2:SUITE 108
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-2689
Practice Address - Country:US
Practice Address - Phone:817-731-8629
Practice Address - Fax:817-732-0563
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX146091223S0112X, 1223S0112X
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126649605Medicaid
75159423576086A002OtherTRICARE
792590OtherUNITED CONCORDIA DENTAL
TX83M212OtherBCBS
0122878002OtherCIGNA
TX4104349OtherAETNA
TX126649605Medicaid
TX83M212OtherBCBS