Basic Information
| Provider Information | |||||||||
| NPI: | 1134567316 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MEHTA | ||||||||
| FirstName: | SAMEER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8337 SUMMER PARK DR | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761231991 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 WOLFE NURSERY RD | ||||||||
| Address2: | 180 | ||||||||
| City: | STEPHENVILLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764013731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2549651931 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2013 | ||||||||
| LastUpdateDate: | 06/10/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 28991 | TX | Y | Dental Providers | Dentist | General Practice |
No ID Information.