WEST TEXAS DENTAL FORT WORTH PLLC

NPI: 1972057024 · FORT WORTH, TX 76112 · General Practice Dentistry · NPI assigned 08/06/2016

$26K

Total Medicaid Paid

1,081

Total Claims

585

Beneficiaries

Codes Billed

2018-05

First Month

2019-12

Last Month

Provider Details

Authorized Official	NGUYEN, CECILE (OWNER)
NPI Enumeration Date	08/06/2016

Other providers sharing the same authorized official: NGUYEN, CECILE

Provider	City	State	Total Paid
ABSOLUTE SMILE DENTAL OF NRH	NORTH RICHLAND HILLS	TX	$375K
ABSOLUTE SMILE DENTAL	DENTON	TX	$300K
ABSOLUTE SMILE DUNCANVILLE PLLC	DUNCANVILLE	TX	$3K

Year	Claims	Total Paid
2018	599	$12K
2019	482	$14K

Code	Description	Claims	Beneficiaries	Total Paid
D1351	Sealant - per tooth	498	72	$14K
D2392	Resin-based composite - two surfaces, posterior, primary or permanent	53	14	$5K
D1120	Prophylaxis - child	55	55	$2K
D1208	Topical application of fluoride, excluding varnish	97	97	$1K
D0230	Intraoral - periapical each additional radiographic image	107	77	$1K
D0220	Intraoral - periapical first radiographic image	77	77	$967.12
D0120	Periodic oral evaluation - established patient	26	25	$721.25
D0272	Bitewings - two radiographic images	13	13	$303.94
D0603		155	155	$0.00