MEDICARE: JSN 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	1223G0001X	General Practice Dentistry	23460	TX

General Provider Information

NPI Number	:	1285994483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JSN DENTAL PLLC

Provider Business Mailing Address
First Line	:	10611 FAULKNER PT
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-5429
Country	:	US
Telephone Number	:	858-231-0299
Fax Number	:

Provider Business Practice Location Address
First Line	:	8849 N TARRANT PKWY
Second Line	:	SUITE# 105
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-7695
Country	:	US
Telephone Number	:	817-381-1122
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. SUGUNA GOTTAM
Credential	:	DDS
Telephone Number	:	817-381-1122

Provider Enumeration Date	:	05/22/2012
Last Update Date	:	05/22/2012

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Directions to “JSN DENTAL PLLC ” Practice Location

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