MEDICARE: MYSTIC SMILES CHILDREN AND ADULT DENTISTRY

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	:	1730938861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MYSTIC SMILES CHILDREN AND ADULT DENTISTRY

Provider Business Mailing Address
First Line	:	1721 LADY BETTYE DR
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75010-6619
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1920 PARKER RD STE 110
Second Line	:
City	:	CARROLLTON
State	:	TX
Zip	:	75010-4864
Country	:	US
Telephone Number	:	469-557-5127
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST
Name	:	AZIZ PRADHAN
Credential	:	DMD
Telephone Number	:	281-202-7938

Provider Enumeration Date	:	05/13/2024
Last Update Date	:	05/13/2024

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Directions to “MYSTIC SMILES CHILDREN AND ADULT DENTISTRY ” Practice Location

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