MEDICARE: SHOAL CREEK DENTAL CARE LLC

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	:	1548011489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHOAL CREEK DENTAL CARE LLC

Provider Business Mailing Address
First Line	:	15660 DALLAS PKWY
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75248-3348
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8568 CHURCH RD
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64157-1202
Country	:	US
Telephone Number	:	816-792-0801
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED REPRESENTATIVE
Name	:	AMANDA LIGHTFOOT
Credential	:
Telephone Number	:	214-702-0708

Provider Enumeration Date	:	03/28/2024
Last Update Date	:	03/28/2024

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Directions to “SHOAL CREEK DENTAL CARE LLC ” Practice Location

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