MEDICARE: PRODIGIOUS DENTAL PC

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

General Provider Information

NPI Number	:	1124593066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRODIGIOUS DENTAL PC

Provider Business Mailing Address
First Line	:	664 SW WILSHIRE BLVD
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-5851
Country	:	US
Telephone Number	:	801-440-2246
Fax Number	:

Provider Business Practice Location Address
First Line	:	664 SW WILSHIRE BLVD
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-5851
Country	:	US
Telephone Number	:	801-440-2246
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ARSHDEEP SOHI
Credential	:	DMD
Telephone Number	:	817-426-3331

Provider Enumeration Date	:	10/08/2018
Last Update Date	:	12/28/2021

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