Healthcare Provider Details

I. General information

NPI: 1205731320
Provider Name (Legal Business Name): MOUNTAIN SMILES - DSS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 W BAILEY BOSWELL RD
SAGINAW TX
76179-1031
US

IV. Provider business mailing address

713 W BAILEY BOSWELL RD
SAGINAW TX
76179-1031
US

V. Phone/Fax

Practice location:
  • Phone: 817-847-4040
  • Fax:
Mailing address:
  • Phone: 817-847-4040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGEL GIMENEZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 719-300-5933