Provider Demographics
NPI:1033580493
Name:SOUTHERN DENTAL SPECIALISTS PLLC
Entity Type:Organization
Organization Name:SOUTHERN DENTAL SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ARNOLD
Authorized Official - Middle Name:
Authorized Official - Last Name:POPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-861-6250
Mailing Address - Street 1:8000 W INTERSTATE 10 STE 407
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-3871
Mailing Address - Country:US
Mailing Address - Phone:210-774-4588
Mailing Address - Fax:210-640-5995
Practice Address - Street 1:310 W 19TH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-3906
Practice Address - Country:US
Practice Address - Phone:713-861-6250
Practice Address - Fax:713-869-6414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-12
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202731223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty