MEDICARE: EAST DALLAS 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	1223D0001X	Public Health Dentistry	33767	TX

General Provider Information

NPI Number	:	1780186205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EAST DALLAS DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	11627 S LOUISVILLE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-8543
Country	:	US
Telephone Number	:	918-695-7616
Fax Number	:

Provider Business Practice Location Address
First Line	:	5429 E GRAND AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75223-1914
Country	:	US
Telephone Number	:	214-377-7312
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JUSTIN MASSEEH EMAMI
Credential	:	DDS
Telephone Number	:	918-695-7616

Provider Enumeration Date	:	02/28/2018
Last Update Date	:	02/28/2018

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