MEDICARE: ORTHODONTIC SPECIALTY GROUP

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	:	1841494754
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHODONTIC SPECIALTY GROUP

Provider Business Mailing Address
First Line	:	PO BOX 14464
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78761-4464
Country	:	US
Telephone Number	:	512-371-1222
Fax Number	:	512-371-3914

Provider Business Practice Location Address
First Line	:	5177 RICHMOND AVE
Second Line	:	SUITE 150
City	:	HOUSTON
State	:	TX
Zip	:	77056-6707
Country	:	US
Telephone Number	:	713-960-9926
Fax Number	:	713-626-2927

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MALCOLM RAY SCOTT
Credential	:	D.D.S.
Telephone Number	:	512-371-1222

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	08/22/2020

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Directions to “ORTHODONTIC SPECIALTY GROUP ” Practice Location

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