Provider Demographics
NPI:1407693997
Name:TX SOUTHERN DENTAL PPO PC
Entity type:Organization
Organization Name:TX SOUTHERN DENTAL PPO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR. CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIKA
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:MENJIVAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-596-6137
Mailing Address - Street 1:5830 GRANITE PKWY STE 780
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-6775
Mailing Address - Country:US
Mailing Address - Phone:469-596-6137
Mailing Address - Fax:
Practice Address - Street 1:5311 KIRBY DR STE 207
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-1339
Practice Address - Country:US
Practice Address - Phone:713-528-0377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty