MEDICARE: INNOVATIVE DENTAL SPECIALISTS OF MCKINNEY 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1891569513
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNOVATIVE DENTAL SPECIALISTS OF MCKINNEY PLLC

Provider Business Mailing Address
First Line	:	6020 VIRGINIA PARKWAY STE 100
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071
Country	:	US
Telephone Number	:	469-448-0066
Fax Number	:

Provider Business Practice Location Address
First Line	:	6020 VIRGINIA PARKWAY STE 100
Second Line	:
City	:	MCKINNEY
State	:	TX
Zip	:	75071
Country	:	US
Telephone Number	:	469-448-0066
Fax Number	:

Authorized Official
Title or Position	:	SR CREDENTIALING TEAM LEAD
Name	:	JENNY GARCIA-ROCHA
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	11/13/2023
Last Update Date	:	11/13/2023

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