Provider Demographics
NPI:1013275585
Name:HOMETOWN DENTAL AT RIDGEMAR
Entity Type:Organization
Organization Name:HOMETOWN DENTAL AT RIDGEMAR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INUSRANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:VARGAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-834-2600
Mailing Address - Street 1:3825 YUCCA AVE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111-6067
Mailing Address - Country:US
Mailing Address - Phone:817-834-2600
Mailing Address - Fax:817-834-2607
Practice Address - Street 1:2374 MALL CIR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-1543
Practice Address - Country:US
Practice Address - Phone:817-543-2222
Practice Address - Fax:817-543-2299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX159871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty