Provider Demographics
NPI:1972001048
Name:FORT WORTH DENTAL CARE PLLC
Entity Type:Organization
Organization Name:FORT WORTH DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:GATLIN
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-923-4606
Mailing Address - Street 1:3646 GRANBURY RD # 104
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3646 GRANBURY RD # 104
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-3717
Practice Address - Country:US
Practice Address - Phone:817-923-4606
Practice Address - Fax:817-923-5593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17178261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
1194835215OtherNPI