MEDICARE: EL CAMPO DENTISTRY 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	:	1437554045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EL CAMPO DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	PO BOX 734753
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75373-4753
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1920 WEST LOOP
Second Line	:
City	:	EL CAMPO
State	:	TX
Zip	:	77437-8007
Country	:	US
Telephone Number	:	979-543-5221
Fax Number	:	979-543-5245

Authorized Official
Title or Position	:	VP OF FINANCE
Name	:	MARY PU
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	10/24/2014
Last Update Date	:	09/09/2022

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