MEDICARE: MICHAEL SOLOMON ORTHODONTICS PA

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	:	1639897820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MICHAEL SOLOMON ORTHODONTICS PA

Provider Business Mailing Address
First Line	:	3006 S W S YOUNG DR
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76542-2023
Country	:	US
Telephone Number	:	254-526-0005
Fax Number	:	254-526-0873

Provider Business Practice Location Address
First Line	:	3006 S W S YOUNG DR
Second Line	:
City	:	KILLEEN
State	:	TX
Zip	:	76542-2023
Country	:	US
Telephone Number	:	254-526-0005
Fax Number	:	254-526-0873

Authorized Official
Title or Position	:	CREDENTIALING MANAGER
Name	:	VICENTA REYES
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	08/15/2022
Last Update Date	:	08/15/2022

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