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928 N Glenwood Blvd Tyler TX 75702-5055 | |
| (903) 526-4900 | |
| (903) 526-4907 |
| Full Name | |
|---|---|
| Speciality | Clinic/center - Federally Qualified Health Center (fqhc) |
| Location | 928 N Glenwood Blvd, Tyler, Texas |
| Authorized Official Name and Position | Bryan F Wilder (CFO) |
| Authorized Official Contact | 9035337400 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
928 N Glenwood Blvd Tyler TX 75702-5055 Ph: (903) 533-7400 | 928 N Glenwood Blvd Tyler TX 75702-5055 Ph: (903) 526-4900 |
| NPI Number | 1275713976 |
|---|---|
| Provider Enumeration Date | 11/09/2007 |
| Last Update Date | 06/21/2010 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1275713976 | NPI | - | NPPES |
| 1383606-17 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0221X | Dentist - Pediatric Dentistry | (* (Not Available)) | Secondary |
| 261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |
Kim Fretty Orthodontics Pllc Dental Clinic Medicare: Not Enrolled in Medicare Practice Location: 6989 Highlands Ln, Tyler, TX 75703 Phone: 903-561-7873 | |
Pediatric Dentistry Of Tyler, Pllc Dental Clinic Medicare: Not Enrolled in Medicare Practice Location: 3607 Old Jacksonville Rd, Tyler, TX 75701 Phone: 903-595-5476 | |