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NPI Code Detail

MEDICARE: DC SOUTHERN DENTAL PPO PC

MEDICARE: DC SOUTHERN DENTAL PPO 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
1122300000XDentist

General Provider Information

NPI Number : 1942013222
Entity Type Code : Organization
Provider Name (Legal Business Name) : DC SOUTHERN DENTAL PPO PC
Provider Business Mailing Address
First Line : 5830 GRANITE PKWY STE 780
Second Line :
City : PLANO
State : TX
Zip : 75024-6775
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 4400 MACARTHUR BLVD NW STE 200
Second Line :
City : WASHINGTON
State : DC
Zip : 20007-2521
Country : US
Telephone Number : 202-333-0003
Fax Number :
Authorized Official
Title or Position : SR. CREDENTIALING SPECIALIST
Name : ERIKA MENJIVAR
Credential :
Telephone Number : 469-596-6137
Provider Enumeration Date : 01/30/2025
Last Update Date : 01/30/2025

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Directions to “DC SOUTHERN DENTAL PPO PC ” Practice Location

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