Provider Demographics
NPI:1982203873
Name:TX SOUTHERN DENTAL PPO PC
Entity Type:Organization
Organization Name:TX SOUTHERN DENTAL PPO PC
Other - Org Name:IMAGECARE DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP, REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-450-6482
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:
Mailing Address - Fax:
Practice Address - Street 1:6841 COIT RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024-5489
Practice Address - Country:US
Practice Address - Phone:972-618-5000
Practice Address - Fax:972-618-9369
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TX SOUTHERN DENTAL PPO PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-10-21
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty