Provider Demographics
NPI:1760781595
Name:FLOSS FT WORTH PC
Entity Type:Organization
Organization Name:FLOSS FT WORTH PC
Other - Org Name:FLOSS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CLINTON
Authorized Official - Middle Name:F
Authorized Official - Last Name:HERZOG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-871-7100
Mailing Address - Street 1:2421 W 7TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2325
Mailing Address - Country:US
Mailing Address - Phone:817-529-1600
Mailing Address - Fax:817-529-1601
Practice Address - Street 1:2421 W 7TH ST STE 103
Practice Address - Street 2:
Practice Address - City:FT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2325
Practice Address - Country:US
Practice Address - Phone:817-529-1600
Practice Address - Fax:817-529-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20239122300000X, 1223G0001X
TX25784122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty