MEDICARE: SOUTH DALLAS DENTAL 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	122300000X	Dentist

General Provider Information

NPI Number	:	1083306807
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH DALLAS DENTAL PLLC

Provider Business Mailing Address
First Line	:	1150 E ELDORADO PKWY STE 100
Second Line	:
City	:	LITTLE ELM
State	:	TX
Zip	:	75068-5502
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6181 BONNIE VIEW RD # 100
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-5149
Country	:	US
Telephone Number	:	972-645-4051
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	MELISSA SIGMAN
Credential	:
Telephone Number	:	972-523-0420

Provider Enumeration Date	:	05/22/2023
Last Update Date	:	05/23/2023

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