MEDICARE: DELTA DENTAL SMILE

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1417651803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELTA DENTAL SMILE

Provider Business Mailing Address
First Line	:	539 W COMMERCE ST # 6909
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75208-1953
Country	:	US
Telephone Number	:	971-999-3399
Fax Number	:

Provider Business Practice Location Address
First Line	:	3125 CRESTDALE DR
Second Line	:	APT #2147
City	:	HOUSTON
State	:	TX
Zip	:	77080
Country	:	US
Telephone Number	:	971-999-3399
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	FARYAAL SHAMSI
Credential	:
Telephone Number	:	971-999-3399

Provider Enumeration Date	:	03/29/2023
Last Update Date	:	01/24/2024

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