Provider Demographics
NPI:1740813195
Name:FORT WORTH SMILEBAR PLLC
Entity type:Organization
Organization Name:FORT WORTH SMILEBAR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MUND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-916-4431
Mailing Address - Street 1:220 E SEMINARY DR STE 100
Mailing Address - Street 2:
Mailing Address - City:FT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76115-2653
Mailing Address - Country:US
Mailing Address - Phone:817-916-4431
Mailing Address - Fax:
Practice Address - Street 1:550 ALTA MERE DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76114-4053
Practice Address - Country:US
Practice Address - Phone:817-286-0044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SMILE NINJA, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-02-13
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty