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General NPI Number Information
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NPI Number | 1114898780
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Entity Type | Organization
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Legal Business Name | TX SOUTHERN DENTAL PPO PC
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Dates
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Enumeration Date | 09/16/2025
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Last Update Date | 09/16/2025
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Provider Practice Location Address
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Address Line | 975 W JOHN CARPENTER FWY STE 115
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City | IRVING
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State | TX
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Zip | 75039-2512
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Country | US
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Telephone | 972-556-1172
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Fax |
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Provider Business Mailing Address
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Address Line | 5830 GRANITE PKWY STE 780
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City | PLANO
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State | TX
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Zip | 75024-6775
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SR. CREDENTIALING MANAGER
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Name | ERIKA MELISSA MENJIVAR
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Credential |
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Telephone | 469-596-6137
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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