MEDICARE: TX SOUTHERN DENTAL PPO PC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1295561538
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TX SOUTHERN DENTAL PPO PC

Provider Business Mailing Address
First Line	:	5830 GRANITE PKWY STE 780
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75024-6775
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1300 VILLAGE CREEK DR
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-4449
Country	:	US
Telephone Number	:	972-905-9266
Fax Number	:

Authorized Official
Title or Position	:	SR. CREDENTIALING SPECIALIST
Name	:	ERIKA MELISSA MENJIVAR
Credential	:
Telephone Number	:	469-596-6137

Provider Enumeration Date	:	09/12/2024
Last Update Date	:	09/12/2024

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