MEDICARE: KALLISON RANCH SMILES 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1922742402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KALLISON RANCH SMILES PLLC

Provider Business Mailing Address
First Line	:	6510 APSLEY CREEK LN
Second Line	:
City	:	SUGAR LAND
State	:	TX
Zip	:	77479-4371
Country	:	US
Telephone Number	:	903-360-8657
Fax Number	:

Provider Business Practice Location Address
First Line	:	14048 CULEBRA RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78253-7225
Country	:	US
Telephone Number	:	903-360-8657
Fax Number	:

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DHAVAL THAKKAR
Credential	:
Telephone Number	:	903-360-8657

Provider Enumeration Date	:	04/21/2022
Last Update Date	:	04/21/2022

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