Healthcare Provider Details

I. General information

NPI: 1073260451
Provider Name (Legal Business Name): SPECIALTY DENTAL MANAGEMENT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2022
Last Update Date: 02/28/2023
Certification Date: 02/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5400 BRODIE LANE SUITE 260
SUNSET VALLEY TX
78745-2525
US

IV. Provider business mailing address

1500 S AW GRIMES BLVD SUITE 190
ROUND ROCK TX
78664
US

V. Phone/Fax

Practice location:
  • Phone: 512-255-5900
  • Fax:
Mailing address:
  • Phone: 512-255-5900
  • Fax: 512-485-2879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JIM B USDAN
Title or Position: CEO
Credential:
Phone: 615-727-3060