MEDICARE: ORTHOSMILES OF EP SOUTH 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1750649232
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ORTHOSMILES OF EP SOUTH PLLC

Provider Business Mailing Address
First Line	:	1620 S PADRE ISLAND DR
Second Line	:	SUITE 230B
City	:	CORPUS CHRISTI
State	:	TX
Zip	:	78416-1353
Country	:	US
Telephone Number	:	361-654-5616
Fax Number	:

Provider Business Practice Location Address
First Line	:	7878 GATEWAY BLVD E
Second Line	:	SUITE 300
City	:	EL PASO
State	:	TX
Zip	:	79915-1838
Country	:	US
Telephone Number	:	361-654-5616
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	CHRISTEL DINKLER
Credential	:	CPA
Telephone Number	:	361-654-5616

Provider Enumeration Date	:	05/02/2012
Last Update Date	:	05/02/2012

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