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NPI Code Detail

MEDICARE: SOUTHERN DENTAL SPECIALISTS PLLC

MEDICARE: SOUTHERN DENTAL SPECIALISTS PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223X0400XOrthodontics and Dentofacial Orthopedics Dentistry20273TX

General Provider Information

NPI Number : 1033580493
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTHERN DENTAL SPECIALISTS PLLC
Provider Business Mailing Address
First Line : 8000 W INTERSTATE 10 STE 407
Second Line :
City : SAN ANTONIO
State : TX
Zip : 78230-3871
Country : US
Telephone Number : 210-774-4588
Fax Number : 210-640-5995
Provider Business Practice Location Address
First Line : 310 W 19TH ST
Second Line :
City : HOUSTON
State : TX
Zip : 77008-3906
Country : US
Telephone Number : 713-861-6250
Fax Number : 713-869-6414
Authorized Official
Title or Position : CREDENTIALING
Name : ARNOLD POPE
Credential :
Telephone Number : 713-861-6250
Provider Enumeration Date : 10/12/2015
Last Update Date : 02/26/2020

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Directions to “SOUTHERN DENTAL SPECIALISTS PLLC ” Practice Location

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