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General NPI Number Information
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NPI Number | 1033580493
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Entity Type | Organization
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Legal Business Name | SOUTHERN DENTAL SPECIALISTS PLLC
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Dates
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Enumeration Date | 10/12/2015
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Last Update Date | 02/26/2020
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Provider Practice Location Address
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Address Line | 310 W 19TH ST
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City | HOUSTON
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State | TX
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Zip | 77008-3906
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Country | US
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Telephone | 713-861-6250
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Fax | 713-869-6414
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Provider Business Mailing Address
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Address Line | 8000 W INTERSTATE 10 STE 407
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City | SAN ANTONIO
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State | TX
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Zip | 78230-3871
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Country | US
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Telephone | 210-774-4588
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Fax | 210-640-5995
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Authorized Official
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Title or Position | CREDENTIALING
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Name | ARNOLD POPE
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Credential |
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Telephone | 713-861-6250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 20273
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License Number State | TX
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