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General NPI Number Information
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NPI Number | 1215856836
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Entity Type | Organization
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Legal Business Name | STAR IMAGE DENTISTRY OF SOUTHLAKE PLLC
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Dates
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Enumeration Date | 07/15/2026
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Last Update Date | 07/15/2026
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Provider Practice Location Address
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Address Line | 1480 CORPORATE CIR STE 100
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City | SOUTHLAKE
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State | TX
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Zip | 76092-5963
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Country | US
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Telephone | 817-587-4566
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Fax | 817-329-0076
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Provider Business Mailing Address
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Address Line | 1480 CORPORATE CIR STE 100
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City | SOUTHLAKE
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State | TX
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Zip | 76092-5963
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Country | US
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Telephone | 817-587-4566
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Fax | 817-329-0076
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Authorized Official
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Title or Position | OFFICE ADMINISTRATOR
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Name | BRENDA RODGERS
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Credential |
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Telephone | 940-322-2252
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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