MEDICARE: SENIORDENT DENTAL CARE OF TEXAS 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	122300000X	Dentist
2	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1922790575
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SENIORDENT DENTAL CARE OF TEXAS PC

Provider Business Mailing Address
First Line	:	2314 S ROUTE 59 STE 384
Second Line	:
City	:	PLAINFIELD
State	:	IL
Zip	:	60586-7756
Country	:	US
Telephone Number	:	888-970-3400
Fax Number	:	888-456-3812

Provider Business Practice Location Address
First Line	:	2901 INDIANA BLVD APT 225
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75226-1558
Country	:	US
Telephone Number	:	888-970-3400
Fax Number	:	888-456-3812

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM SELMER
Credential	:	DDS
Telephone Number	:	888-970-3400

Provider Enumeration Date	:	05/23/2023
Last Update Date	:	05/23/2023

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