MEDICARE: THE SMILE CLUB DENTISTRY AND ORTHODONTICS PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	1223E0200X	Endodontics
2	1223D0001X	Public Health Dentistry
3	1223D0004X	Dental Anesthesiology
4	1223G0001X	General Practice Dentistry
5	1223P0106X	Oral and Maxillofacial Pathology Dentistry
6	1223P0221X	Pediatric Dentistry
7	1223P0300X	Periodontics
8	1223P0700X	Prosthodontics
9	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
10	1223X0008X	Oral and Maxillofacial Radiology Dentistry
11	124Q00000X	Dental Hygienist
12	125J00000X	Dental Therapist
13	126800000X	Dental Assistant
14	126900000X	Dental Laboratory Technician
15	122300000X	Dentist

General Provider Information

NPI Number	:	1265999379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE SMILE CLUB DENTISTRY AND ORTHODONTICS PLLC

Provider Business Mailing Address
First Line	:	777 PRESTON ST APT 30A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77002-1774
Country	:	US
Telephone Number	:	954-478-9319
Fax Number	:

Provider Business Practice Location Address
First Line	:	6421 W 43RD ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77092-4005
Country	:	US
Telephone Number	:	954-478-9319
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JASON WILLIAMS
Credential	:	DMD
Telephone Number	:	954-478-9319

Provider Enumeration Date	:	02/25/2019
Last Update Date	:	02/25/2019

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