MEDICARE: DENTAL IMPLANT SURGERY CENTER

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	1223P0300X	Periodontics	18760	TX

General Provider Information

NPI Number	:	1134158330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL IMPLANT SURGERY CENTER

Provider Business Mailing Address
First Line	:	7965 CUSTER ROAD
Second Line	:	SUITE 114
City	:	PLANO
State	:	TX
Zip	:	75025-3155
Country	:	US
Telephone Number	:	972-527-4867
Fax Number	:	972-665-1818

Provider Business Practice Location Address
First Line	:	7965 CUSTER ROAD
Second Line	:	SUITE 114
City	:	PLANO
State	:	TX
Zip	:	75025-3155
Country	:	US
Telephone Number	:	972-527-4867
Fax Number	:	972-665-1818

Authorized Official
Title or Position	:	PRINCIPAL SURGEON, PRESIDENT
Name	:	DR. EDWARD A SHINEDLING
Credential	:	DDS, MS
Telephone Number	:	972-527-4867

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	05/04/2009

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