Provider Demographics
NPI:1083401616
Name:SOUTH LOOP DENTAL SERVICES, PLLC
Entity type:Organization
Organization Name:SOUTH LOOP DENTAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-398-5329
Mailing Address - Street 1:PO BOX 8144
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77288-8144
Mailing Address - Country:US
Mailing Address - Phone:713-398-5329
Mailing Address - Fax:
Practice Address - Street 1:3577 YELLOWSTONE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77021-2440
Practice Address - Country:US
Practice Address - Phone:713-398-5329
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1851685697Medicaid