Healthcare Provider Details

I. General information

NPI: 1700710381
Provider Name (Legal Business Name): TX SOUTHERN DENTAL PPO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 N HIGHWAY 183 STE 150
LEANDER TX
78641-7006
US

IV. Provider business mailing address

5830 GRANITE PKWY STE 780
PLANO TX
75024-6775
US

V. Phone/Fax

Practice location:
  • Phone: 512-260-0123
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ERIKA MELISSA MENJIVAR
Title or Position: SR. CREDENTIALING SPECIALIST
Credential:
Phone: 469-596-6137