=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194604066
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE SMILE CENTER OF THE WOODLANDS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2025
-----------------------------------------------------
Last Update Date | 08/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 VISION PARK BLVD STE 130
-----------------------------------------------------
City | SHENANDOAH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77384-3028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-404-2808
-----------------------------------------------------
Fax | 832-409-0201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 VISION PARK BLVD STE 130
-----------------------------------------------------
City | SHENANDOAH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77384-3028
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-404-2808
-----------------------------------------------------
Fax | 832-409-0201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST OWNER
-----------------------------------------------------
Name | DR. ROSE MICHELLE CANTU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 832-404-2808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------