Provider Demographics
NPI:1104939024
Name:FORT WORTH DENTAL
Entity type:Organization
Organization Name:FORT WORTH DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:JACKSON
Authorized Official - Last Name:MUND
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-263-0202
Mailing Address - Street 1:4620 CITYLAKE BLVD W
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-3695
Mailing Address - Country:US
Mailing Address - Phone:817-263-0202
Mailing Address - Fax:817-927-7197
Practice Address - Street 1:4620 CITYLAKE BLVD W
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3695
Practice Address - Country:US
Practice Address - Phone:817-263-0202
Practice Address - Fax:817-927-7197
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ARTHUR J MUND III DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13209122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX809903OtherUNITED CONCORDIA #
TX25DGOtherBCBS OF TX PROVIDER #
TX84D741OtherBCBS PROVIDER #