Healthcare Provider Details

I. General information

NPI: 1073221107
Provider Name (Legal Business Name): ODP OF TEXAS ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10920 FRY RD STE 650
CYPRESS TX
77433-4147
US

IV. Provider business mailing address

2300 LAKEVIEW PKWY STE 250
ALPHARETTA GA
30009-3954
US

V. Phone/Fax

Practice location:
  • Phone: 281-373-5437
  • Fax:
Mailing address:
  • Phone: 470-207-3264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: NICOLE CARIDE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 470-207-3264