Healthcare Provider Details

I. General information

NPI: 1659199727
Provider Name (Legal Business Name): ODP OF TEXAS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2024
Last Update Date: 09/28/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 BENNEY LN STE 103
DRIPPING SPRINGS TX
78620-5566
US

IV. Provider business mailing address

2300 LAKEVIEW PKWY STE 250
ALPHARETTA GA
30009-3954
US

V. Phone/Fax

Practice location:
  • Phone: 512-894-3779
  • Fax:
Mailing address:
  • Phone: 470-207-3264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

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