Healthcare Provider Details

I. General information

NPI: 1003136714
Provider Name (Legal Business Name): TEXARKANA DENTAL SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 TEXAS BLVD
TEXARKANA TX
75503-4109
US

IV. Provider business mailing address

2800 TEXAS BLVD
TEXARKANA TX
75503-4109
US

V. Phone/Fax

Practice location:
  • Phone: 903-792-3636
  • Fax: 903-792-0062
Mailing address:
  • Phone: 903-792-3636
  • Fax: 903-792-0062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number22320
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22346
License Number StateTX

VIII. Authorized Official

Name: DR. SANDRA L SHAMBARGER
Title or Position: VICE-PRESIDENT
Credential: DDS, MS
Phone: 903-792-3636