MEDICARE: BAYSIDE DENTAL OF MESQUITE 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

General Provider Information

NPI Number	:	1467300350
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BAYSIDE DENTAL OF MESQUITE PLLC

Provider Business Mailing Address
First Line	:	5938 W PARKER RD
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-6438
Country	:	US
Telephone Number	:	972-608-1811
Fax Number	:

Provider Business Practice Location Address
First Line	:	5938 W PARKER RD
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75093-6438
Country	:	US
Telephone Number	:	972-608-1811
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LOI TA
Credential	:	DDS
Telephone Number	:	972-608-1811

Provider Enumeration Date	:	03/18/2026
Last Update Date	:	03/18/2026

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