MEDICARE: ST. JUDE DENTAL P.C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	22568	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053637199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. JUDE DENTAL P.C

Provider Business Mailing Address
First Line	:	1001 N BECKLEY AVE #420C
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115
Country	:	US
Telephone Number	:	972-224-5397
Fax Number	:	972-224-0344

Provider Business Practice Location Address
First Line	:	8420 S SAM HOUSTON PKWY W STE 260
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77085-2283
Country	:	US
Telephone Number	:	972-224-5397
Fax Number	:	972-224-0344

Authorized Official
Title or Position	:	DENTIST
Name	:	EMEKA JUDE ABAZIE
Credential	:	DDS
Telephone Number	:	972-224-5397

Provider Enumeration Date	:	04/14/2010
Last Update Date	:	04/14/2010

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Directions to “ST. JUDE DENTAL P.C ” Practice Location

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