MEDICARE: ALBA DENTAL CARE, 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	261QD0000X	Dental Clinic/Center
2	122300000X	Dentist

General Provider Information

NPI Number	:	1770243974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALBA DENTAL CARE, PLLC

Provider Business Mailing Address
First Line	:	12444 EDGEMERE BLVD
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938-4445
Country	:	US
Telephone Number	:	915-800-2522
Fax Number	:	888-597-6775

Provider Business Practice Location Address
First Line	:	12444 EDGEMERE BLVD.
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79938
Country	:	US
Telephone Number	:	915-800-2522
Fax Number	:	888-597-6775

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SOHEIL KHODADADI
Credential	:	DDS
Telephone Number	:	915-800-2522

Provider Enumeration Date	:	12/29/2021
Last Update Date	:	04/13/2026

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