MEDICARE: SMILEY DENTAL TIDWELL 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
1	1223G0001X	General Practice Dentistry	19887	TX

General Provider Information

NPI Number	:	1073821104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILEY DENTAL TIDWELL PLLC

Provider Business Mailing Address
First Line	:	PO BOX 453247
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75045-3247
Country	:	US
Telephone Number	:	214-718-7880
Fax Number	:

Provider Business Practice Location Address
First Line	:	9417 MESA DR
Second Line	:	STE A
City	:	HOUSTON
State	:	TX
Zip	:	77028-1253
Country	:	US
Telephone Number	:	214-718-7880
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LYNH PHAM
Credential	:	DDS
Telephone Number	:	214-718-7880

Provider Enumeration Date	:	09/23/2010
Last Update Date	:	09/23/2010

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