MEDICARE: DCP OF SOUTHRIDGE SHOPPING CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223P0221X	Pediatric Dentistry
2	1223P0300X	Periodontics
3	1223P0700X	Prosthodontics
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
5	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
6	122300000X	Dentist
7	1223E0200X	Endodontics
8	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1568435253
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DCP OF SOUTHRIDGE SHOPPING CENTER, LLC

Provider Business Mailing Address
First Line	:	7160 NORTH DALLAS PARKWAY
Second Line	:	SUITE 400
City	:	PLANO
State	:	TX
Zip	:	75024
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7995 W LAYTON AVE
Second Line	:
City	:	GREENFIELD
State	:	WI
Zip	:	53220-3710
Country	:	US
Telephone Number	:	414-282-6583
Fax Number	:	216-584-1020

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	MS. RACHEL NITTINGER
Credential	:
Telephone Number	:	972-755-0816

Provider Enumeration Date	:	02/11/2006
Last Update Date	:	03/19/2018

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Directions to “DCP OF SOUTHRIDGE SHOPPING CENTER, LLC ” Practice Location

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