MEDICARE: MOBILE SMILES OF TEXAS

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1689951196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE SMILES OF TEXAS

Provider Business Mailing Address
First Line	:	6107 MARTEL AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-3025
Country	:	US
Telephone Number	:	936-554-0669
Fax Number	:	936-598-6412

Provider Business Practice Location Address
First Line	:	6107 MARTEL AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75214-3025
Country	:	US
Telephone Number	:	936-554-0996
Fax Number	:	936-598-6412

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ANNA JOY WINDHAM SHIRLEY
Credential	:	DDS
Telephone Number	:	936-554-0996

Provider Enumeration Date	:	11/11/2011
Last Update Date	:	11/11/2011

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