MEDICARE: THE DENTAL EDGE OF HOUSTON, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	122300000X	Dentist
2	1223E0200X	Endodontics
3	1223P0221X	Pediatric Dentistry
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
5	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1629448626
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE DENTAL EDGE OF HOUSTON, PC

Provider Business Mailing Address
First Line	:	1090 NORTHCHASE PKWY SE STE 150
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30067-6407
Country	:	US
Telephone Number	:	770-916-5031
Fax Number	:

Provider Business Practice Location Address
First Line	:	21177 STATE HIGHWAY 249
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-1655
Country	:	US
Telephone Number	:	281-370-9442
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JUSTIN JONES
Credential	:	D.D.S.
Telephone Number	:	281-370-9442

Provider Enumeration Date	:	10/02/2015
Last Update Date	:	12/06/2016

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