Provider Demographics
NPI:1073260451
Name:SPECIALTY DENTAL MANAGEMENT LLC
Entity Type:Organization
Organization Name:SPECIALTY DENTAL MANAGEMENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JIM
Authorized Official - Middle Name:B
Authorized Official - Last Name:USDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-727-3060
Mailing Address - Street 1:1500 S AW GRIMES BLVD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664
Mailing Address - Country:US
Mailing Address - Phone:512-255-5900
Mailing Address - Fax:512-485-2879
Practice Address - Street 1:5400 BRODIE LANE
Practice Address - Street 2:SUITE 260
Practice Address - City:SUNSET VALLEY
Practice Address - State:TX
Practice Address - Zip Code:78745-2525
Practice Address - Country:US
Practice Address - Phone:512-255-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty