MEDICARE: SUN ORTHODONTIX OF WEST EL PASO, PLLC

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry		TX

General Provider Information

NPI Number	:	1063778678
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUN ORTHODONTIX OF WEST EL PASO, PLLC

Provider Business Mailing Address
First Line	:	1620 S PADRE ISLAND DR
Second Line	:	SUITE 230B
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78416-1353
Country	:	US
Telephone Number	:	361-654-5616
Fax Number	:

Provider Business Practice Location Address
First Line	:	7500 N MESA ST
Second Line	:	SUITE 304
City	:	EL PASO
State	:	TX
Zip	:	79912-3501
Country	:	US
Telephone Number	:	915-231-9983
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	CHRISTEL DINKLER
Credential	:	CPA
Telephone Number	:	361-654-5616

Provider Enumeration Date	:	04/09/2012
Last Update Date	:	04/09/2012

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