MEDICARE: SD-HWY 78 PC

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	19887	TX

General Provider Information

NPI Number	:	1821549130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SD-HWY 78 PC

Provider Business Mailing Address
First Line	:	10901 GARLAND RD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75218-2613
Country	:	US
Telephone Number	:	214-466-1400
Fax Number	:	214-367-5896

Provider Business Practice Location Address
First Line	:	6735 FM 78
Second Line	:	SUITE 106
City	:	SAN ANTONIO
State	:	TX
Zip	:	78244-1367
Country	:	US
Telephone Number	:	210-667-2929
Fax Number	:	210-661-2575

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LYNHTHY THY PHAM
Credential	:	DDS
Telephone Number	:	214-466-1400

Provider Enumeration Date	:	10/21/2016
Last Update Date	:	10/21/2016

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