MEDICARE: TX SDS II, LLC

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

General Provider Information

NPI Number	:	1619730827
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TX SDS II, LLC

Provider Business Mailing Address
First Line	:	1610 54TH AVE N STE 205
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37209-1442
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7700 SAN FELIPE ST STE 250
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77063-1634
Country	:	US
Telephone Number	:	713-781-5548
Fax Number	:

Authorized Official
Title or Position	:	DIREC OF CRED AND PROV REL
Name	:	CHARLOTTE V DASCH
Credential	:
Telephone Number	:	504-638-0303

Provider Enumeration Date	:	01/31/2024
Last Update Date	:	03/05/2025

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