MEDICARE: DENTAL DEPOT OF LITTLE ELM, 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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1336233022	OTHER	TX	NPI
2	1548381536	OTHER	TX	NPI
3	1982736864	OTHER	TX	NPI

General Provider Information

NPI Number	:	1306400411
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL DEPOT OF LITTLE ELM, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 561205
Second Line	:
City	:	THE COLONY
State	:	TX
Zip	:	75056
Country	:	US
Telephone Number	:	972-703-2525
Fax Number	:	972-332-0141

Provider Business Practice Location Address
First Line	:	26747 E UNIVERSITY DR.
Second Line	:
City	:	AUBREY
State	:	TX
Zip	:	76227
Country	:	US
Telephone Number	:	972-884-0065
Fax Number	:	972-863-0499

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MS. HIMESH I KANA
Credential	:	DDS
Telephone Number	:	729-758-8999

Provider Enumeration Date	:	04/24/2019
Last Update Date	:	11/22/2019

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Directions to “DENTAL DEPOT OF LITTLE ELM, PLLC ” Practice Location

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