Healthcare Provider Details

I. General information

NPI: 1144988957
Provider Name (Legal Business Name): SOUTHGLENN DENTAL CARE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6650 S VINE ST STE 200
CENTENNIAL CO
80121-2763
US

IV. Provider business mailing address

7160 DALLAS PKWY STE 400
PLANO TX
75024-7111
US

V. Phone/Fax

Practice location:
  • Phone: 303-797-3636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. ANGELA EISWERTH
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 770-833-0994