Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer...

23
Concordia Plus Schedule of Benefits Transport Workers Union IMPORTANT INFORMATION ABOUT YOUR PLAN This schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment, the amount to be paid is shown in the column titled “Member Pays $.” You pay these copayments to the dental office at the time of service. 4 You must select a United Concordia Primary Dental Office (PDO) to receive covered services. Your PDO will perform the below procedures or refer you to a specialty care dentist for further care. Treatment by an Out-of-Network dentist is not covered, except as described in the Certificate of Coverage. 4 Only procedures listed on this Schedule of Benefits are Covered Services. For services not listed (not covered), You are responsible for the full fee charged by the dentist. Procedure codes and member Copayments may be updated to meet American Dental Association (ADA) Current Dental Terminology (CDT) in accordance with national standards. 4 For a complete description of your plan, please refer to the Certificate of Coverage and the Schedule of Exclusions and Limitations in addition to this Schedule of Benefits. 4 If you have any questions about your United Concordia dental plan, please call our Customer Service Department toll-free at 1-866- 357-3304 or access our website at www.UnitedConcordia.com. 4 ADA Code ADA Description Member Pays $ CLINICAL ORAL EVALUATIONS D0120 0 Periodic Oral Evaluation - Established Patient D0140 0 Limited Oral Evaluation - Problem Focused D0150 0 Comprehensive Oral Evaluation - New Or Established Patient D0160 0 Detailed And Extensive Oral Evaluation - Problem Focused, By Report D0170 0 Re-Evaluation-Limited, Problem Focused (Established Patient; Not Post-Operative Visit) D0180 0 Comprehensive Periodontal Evaluation RADIOGRAPHS/DIAGNOSTIC IMAGING (including interpretation) D0210 0 Intraoral - Complete Series Of Radiographic Images D0220 0 Intraoral- Periapical First Radiographic Image D0230 0 Intraoral- Periapical Each Additional Radiographic Image D0240 0 Intraoral - Occlusal Radiographic Image D0250 0 Extra-oral - 2D Projection Radiographic Image Created Using A Stationary Radiation Source, And Detector D0270 0 Bitewing - Single Radiographic Image D0272 0 Bitewings - Two Radiographic Images D0273 0 Bitewings - Three Radiographic Images D0274 0 Bitewings - Four Radiographic Images D0277 0 Vertical Bitewings - 7 To 8 Radiographic Images D0330 0 Panoramic Radiographic Image TESTS AND EXAMINATIONS D0415 0 Collection Of Microorganisms For Culture And Sensitivity D0425 0 Caries Susceptibility Tests D0431 20 Adjunctive Pre-Diagnostic Test That Aids In Detection Of Mucosal Abnormalities Including Premalignant And Malignant Lesions, Not To Include Cytology Or Biopsy Procedures D0460 0 Pulp Vitality Tests ADA Code ADA Description Member Pays $ TESTS AND EXAMINATIONS D0470 0 Diagnostic Casts ORAL PATHOLOGY LABORATORY D0472 0 Accession Of Tissue, Gross Examination, Preparation And Transmission Of Written Report D0473 0 Accession Of Tissue, Gross And Microscopic Examination, Preparation And Transmission Of Written Report D0474 0 Accession Of Tissue, Gross And Microscopic Examination, Including Assessment Of Surgical Margins For Presence Of Disease, Preparation And Transmission Of Written Report DENTAL PROPHYLAXIS D1110 0 25 Prophylaxis, Adult Each additional prophylaxis within 6 months based upon the necessity recommended by the Dentist D1120 0 25 Prophylaxis, Child Each additional prophylaxis within 6 months based upon the necessity recommended by the Dentist TOPICAL FLUORIDE TREATMENT (office procedure) D1206 0 Topical Application Of Fluoride Varnish D1208 0 Topical Application Of Flouride Excluding Varnish OTHER PREVENTIVE SERVICES D1310 0 Nutritional Counseling For The Control Of Dental Disease D1320 0 Tobacco Counseling For The Control And Prevention Of Oral Disease D1330 0 Oral Hygiene Instruction D1351 5 Sealant - Per Tooth D1353 5 Sealant Repair - Per Tooth TWU Current Dental Terminology ©2019 American Dental Association. All rights reserved. Page 1 TWU 20 (06/19) TWU

Transcript of Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer...

Page 1: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

Concordia Plus Schedule of Benefits Transport Workers Union

IMPORTANT INFORMATION ABOUT YOUR PLANThis schedule of benefits provides a listing of procedures covered by your plan. For procedures that require a copayment, the amount to be paid is shown in the column titled “Member Pays $.” You pay these copayments to the dental office at the time of service.

4

You must select a United Concordia Primary Dental Office (PDO) to receive covered services. Your PDO will perform the below procedures or refer you to a specialty care dentist for further care. Treatment by an Out-of-Network dentist is not covered, except as described in the Certificate of Coverage.

4

Only procedures listed on this Schedule of Benefits are Covered Services. For services not listed (not covered), You are responsible for the full fee charged by the dentist. Procedure codes and member Copayments may be updated to meet American Dental Association (ADA) Current Dental Terminology (CDT) in accordance with national standards.

4

For a complete description of your plan, please refer to the Certificate of Coverage and the Schedule of Exclusions and Limitations in addition to this Schedule of Benefits.

4

If you have any questions about your United Concordia dental plan, please call our Customer Service Department toll-free at 1-866-357-3304 or access our website at www.UnitedConcordia.com.

4

ADA Code

ADA Description

Member Pays $

CLINICAL ORAL EVALUATIONS

D0120 0Periodic Oral Evaluation - Established Patient

D0140 0Limited Oral Evaluation - Problem Focused

D0150 0Comprehensive Oral Evaluation - New Or Established Patient

D0160 0Detailed And Extensive Oral Evaluation - Problem Focused, By Report

D0170 0Re-Evaluation-Limited, Problem Focused (Established Patient; Not Post-Operative Visit)

D0180 0Comprehensive Periodontal EvaluationRADIOGRAPHS/DIAGNOSTIC IMAGING (including interpretation)

D0210 0Intraoral - Complete Series Of Radiographic Images

D0220 0Intraoral- Periapical First Radiographic Image

D0230 0Intraoral- Periapical Each Additional Radiographic Image

D0240 0Intraoral - Occlusal Radiographic Image

D0250 0Extra-oral - 2D Projection Radiographic Image Created Using A Stationary Radiation Source, And Detector

D0270 0Bitewing - Single Radiographic Image

D0272 0Bitewings - Two Radiographic Images

D0273 0Bitewings - Three Radiographic Images

D0274 0Bitewings - Four Radiographic Images

D0277 0Vertical Bitewings - 7 To 8 Radiographic Images

D0330 0Panoramic Radiographic ImageTESTS AND EXAMINATIONS

D0415 0Collection Of Microorganisms For Culture And Sensitivity

D0425 0Caries Susceptibility Tests

D0431 20Adjunctive Pre-Diagnostic Test That Aids In Detection Of Mucosal Abnormalities Including Premalignant And Malignant Lesions, Not To Include Cytology Or Biopsy Procedures

D0460 0Pulp Vitality Tests

ADA Code

ADA Description

Member Pays $

TESTS AND EXAMINATIONS

D0470 0Diagnostic CastsORAL PATHOLOGY LABORATORY

D0472 0Accession Of Tissue, Gross Examination, Preparation And Transmission Of Written Report

D0473 0Accession Of Tissue, Gross And Microscopic Examination, Preparation And Transmission Of Written Report

D0474 0Accession Of Tissue, Gross And Microscopic Examination, Including Assessment Of Surgical Margins For Presence Of Disease, Preparation And Transmission Of Written Report

DENTAL PROPHYLAXIS

D1110 0

25

Prophylaxis, Adult

Each additional prophylaxis within 6 months based upon the necessity recommended by the Dentist

D1120 0

25

Prophylaxis, Child

Each additional prophylaxis within 6 months based upon the necessity recommended by the DentistTOPICAL FLUORIDE TREATMENT (office procedure)

D1206 0Topical Application Of Fluoride Varnish

D1208 0Topical Application Of Flouride ‐ Excluding Varnish

OTHER PREVENTIVE SERVICES

D1310 0Nutritional Counseling For The Control Of Dental Disease

D1320 0Tobacco Counseling For The Control And Prevention Of Oral Disease

D1330 0Oral Hygiene Instruction

D1351 5Sealant - Per Tooth

D1353 5Sealant Repair - Per Tooth

TWUCurrent Dental Terminology ©2019 American Dental Association. All rights reserved. Page 1TWU 20 (06/19) TWU

Page 2: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

ADA Code

ADA Description

Member Pays $

SPACE MAINTENANCE (passive appliances)

D1510 25Space maintainer - fixed, unilateral - per quadrant

D1516 25Space Maintainer - Fixed - bilateral, maxillary

D1517 25Space Maintainer - Fixed - bilateral, mandibular

D1520 35Space maintainer - removable, unilateral - per quadrant

D1526 35Space Maintainer - Removable - bilateral, maxillary

D1527 35Space Maintainer - Removable - bilateral, mandibular

D1551 5Re-cement or re-bond bilateral space maintainer - maxillary

D1552 5Re-cement or re-bond bilateral space maintainer - mandibular

D1553 5Re-cement or re-bond bilateral space maintainer - per quadrant

D1556 10Removal of fixed unilateral space maintainer - per quadrant

D1557 10Removal of fixed unilateral space maintainer - maxillary

D1558 10Removal of fixed unilateral space maintainer - mandibular

D1575 25Distal shoe space maintainer - fixed, unilateral - per quadrant

AMALGAM RESTORATIONS (including polishing)

D2140 0Amalgam - One Surface, Primary Or Permanent

D2150 0Amalgam - Two Surfaces, Primary Or Permanent

D2160 0Amalgam - Three Surfaces, Primary Or Permanent

D2161 0Amalgam - Four Or More Surfaces, Primary Or Permanent

RESIN-BASED COMPOSITE RESTORATIONS - DIREC

D2330 0Resin-Based Composite - One Surface, Anterior

D2331 0Resin-Based Composite - Two Surfaces, Anterior

D2332 0Resin-Based Composite - Three Surfaces, Anterior

D2335 0Resin-Based Composite - Four Or More Surfaces Or Involving Incisal Angle (Anterior)

D2390 25Resin-Based Composite Crown, Anterior

D2391 30Resin-Based Composite - One Surface, Posterior

D2392 40Resin-Based Composite - Two Surfaces, Posterior

D2393 55Resin-Based Composite - Three Surfaces, Posterior

D2394 55Resin-Based Composite - Four Or More Surfaces, Posterior

INLAY/ONLAY RESTORATIONS

D2510 150Inlay - Metallic - One Surface u

D2520 150Inlay - Metallic - Two Surfaces u

D2530 150Inlay - Metallic - Three Or More Surfaces u

D2542 150Onlay - Metallic-Two Surfaces u

D2543 150Onlay - Metallic - Three Surfaces u

D2544 150Onlay - Metallic - Four Or More Surfaces u

D2610 175Inlay - Porcelain/Ceramic--One Surface

D2620 175Inlay - Porcelain/Ceramic - Two Surfaces

ADA Code

ADA Description

Member Pays $

INLAY/ONLAY RESTORATIONS

D2630 175Inlay - Porcelain/Ceramic - Three Or More Surfaces

D2642 175Onlay - Porcelain/Ceramic Two Surfaces

D2643 175Onlay - Porcelain/Ceramic Three Surfaces

D2644 175Onlay - Porcelain Ceramic Four Or More Surfaces

D2650 175Inlay - Resin-Based Composite -One Surface

D2651 175Inlay-Resin-Based Composite - Two Surfaces

D2652 175Inlay - Resin-Based Composite -Three Or More Surfaces

D2662 175Onlay - Resin-Based Composite -Two Surfaces

D2663 175Onlay - Resin-Based Composite -Three Surfaces

D2664 175Onlay - Resin-Based Composite - Four Or More Surfaces

CROWNS - SINGLE RESTORATIONS ONLY

D2710 125Crown-Resin-Based Composite (Indirect)

D2712 125Crown - 3/4 Resin-Based Composite (Indirect)

D2720 175Crown, Resin With High Noble Metal u

D2721 175Crown, Resin With Predominantly Base Metal

D2722 175Crown, Resin With Noble Metal u

D2740 225Crown, Porcelain/Ceramic

D2750 175Crown, Porcelain Fused To High Noble Metal u

D2751 175Crown-Porcelain Fused To Predominantly Base Metal

D2752 175Crown, Porcelain Fused To Noble Metal u

D2753 175Crown - porcelain fused to titanium and titanium alloys

D2780 175Crown - 3/4 Cast High Noble Metal u

D2781 175Crown - 3/4 Cast Predominantly Base Metal

D2782 175Crown - 3/4 Cast Noble Metal u

D2783 175Crown - 3/4 Porcelain/Ceramic

D2790 175Crown, Full Cast High Noble Metal u

D2791 175Crown - Full Cast Predominantly Base Metal

D2792 175Crown, Full Cast Noble Metal u

D2794 175Crown - titanium and titanium alloysOTHER RESTORATIVE SERVICES

D2910 0Re-Cement Or Re‐Bond Inlay, Onlay, Veneer Or Partial Coverage Restoration

D2915 0Re‐Cement Or Rebond Indirectly Fabricated Or Prefabricated Post And Core

D2920 0Re-Cement Or Re‐Bond Crown

D2930 25Prefabricated Stainless Steel Crown - Primary Tooth

D2931 25Prefabricated Stainless Steel Crown - Permanent Tooth

D2932 35Prefabricated Resin Crown

D2933 35Prefabricated Stainless Steel Crown With Resin Window

D2940 0Protective Restoration

D2950 25Core Buildup Including Any Pins When Required

D2951 10Pin Retention - Per Tooth, In Addition To Restoration

D2952 35Post And Core In Addition To Crown, Indirectly Fabricated

D2953 25Each Additional Indirectly Fabricated Post - Same Tooth

TWUCurrent Dental Terminology ©2019 American Dental Association. All rights reserved. Page 2TWU 20 (06/19) TWU

Page 3: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

ADA Code

ADA Description

Member Pays $

OTHER RESTORATIVE SERVICES

D2954 20Prefabricated Post And Core In Addition To Crown

D2955 10Post Removal

D2957 30Each Additional Prefabricated Post - Same Tooth

D2971 35Additional Procedures To Construct New Crown Under Existing Partial Denture Framework

PULP CAPPING

D3110 0Pulp Cap - Direct (Excluding Final Restoration)

D3120 0Pulp Cap - Indirect (Excluding Final Restoration)

PULPOTOMY

D3220 0Therapeutic Pulpotomy (Excluding Final Restoration)

D3221 15Pulpal Debridement, Primary And Permanent Teeth

ENDODONTIC THERAPY ON PRIMARY TEETH

D3230 25Pulpal Therapy (Resorbable Filling)-Anterior, Primary Tooth (Excluding Final Restoration)

D3240 25Pulpal Therapy (Resorbable Filling)-Posterior, Primary Tooth (Excluding Final Restoration)

ENDODONTIC THERAPY (including treatment plan, clinical procedures and follow-up care)

D3310 75Endodontic Therapy, Anterior Tooth (Excluding Final Restoration)

D3320 150Endodontic Therapy, Premolar Tooth (Excluding Final Restoration)

D3330 275Endodontic Therapy, Molar Tooth (Excluding Final Restoration)

D3331 85Treatment Of Root Canal Obstruction; Non-Surgical Access

D3332 65Incomplete Endodontic Therapy; Inoperable Unrestorable Or Fractured Tooth

D3333 65Internal Root Repair Of Perforation DefectsENDODONTIC RETREATMENT

D3346 100Retreatment Of Previous Root Canal Therapy - Anterior

D3347 170Retreatment Or Previous Root Canal Therapy - Premolar

D3348 295Retreatment Of Previous Root Canal Therapy - MolarAPEXIFICATION/RECALCIFICATION PROCEDURES

D3351 65Apexification/Recalcification ‐ Initial Visit (Apical Closure / Calcific Repair Of Perforations, Root Resorption, Etc.)

D3352 65Apexification/Recalcification - Interim Medication Replacement (Apical Closure/Calcific Repair Of Perforations, Root Resorption, Pulpal Space Disinfection, Etc.)

D3353 65Apexification/Recalcification-Final Visit (Includes Completed Root Canal Therapy-Apical Closure/Calcific Repair Of Perforations, Root Resorption, Etc.)

APICOECTOMY/PERIRADICULAR SERVICES

D3410 95Apicoectomy - Anterior

D3421 95Apicoectomy - Premolar (First Root)

D3425 95Apicoectomy - Molar (First Root)

D3426 55Apicoectomy (Each Additional Root)

D3427 95Periradicular Surgery Without Apicoectomy

ADA Code

ADA Description

Member Pays $

APICOECTOMY/PERIRADICULAR SERVICES

D3430 55Retrograde Filling - Per Root

D3450 95Root Amputation - Per RootOTHER ENDODONTIC PROCEDURES

D3910 15Surgical Procedure For Isolation Of Tooth With Rubber Dam

D3920 90Hemisection (Including Any Root Removal) Not Including Root Canal Therapy

D3950 15Canal Preparation And Fitting Of Preformed Dowel Or Post

SURGICAL SERVICES (including usual postoperative care)

D4210 115Gingivectomy Or Gingivoplasty - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4211 75Gingivectomy Or Gingivoplasty - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4240 140Gingival Flap Procedure, Including Root Planing - Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4241 85Gingival Flap Procedure, Including Root Planing - One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4245 165Apically Positioned Flap

D4249 115Clinical Crown Lengthening-Hard Tissue

D4260 325Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) – Four Or More Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4261 215Osseous Surgery (Including Elevation Of A Full Thickness Flap And Closure) – One To Three Contiguous Teeth Or Tooth Bounded Spaces Per Quadrant

D4263 175Bone Replacement Graft - Retained Natural Tooth - First Site In Quadrant

D4264 75Bone Replacement Graft - Retained Natural Tooth - Each Additional Site In Quadrant

D4270 215Pedicle Soft Tissue Graft Procedure

D4274 65Mesial/Distal Wedge Procedure, Single Tooth (When Not Performed In Conjunction With Surgical Procedures In The Same Anatomical Area)

D4277 215Free Soft Tissue Graft Procedure (Including Recipient And Donor Surgical Sites), First Tooth, Implant, Or Edentulous Tooth Position In A Graft

D4278 215Free Soft Tissue Graft Procedure (Including Recipient And Donor Surgical Sites), Each Additional Contiguous Tooth, Implant, Or Edentulous Tooth Position In Same Graft Site

NON-SURGICAL PERIODONTAL SERVICES

D4341 40Periodontal Scaling And Root Planing - Four Or More Teeth Per Quadrant

D4342 28Periodontal Scaling And Root Planing - One To Three Teeth Per Quadrant

D4346 30Scaling In Presence Of Generalized Moderate Or Severe Gingival Inflammation - Full Mouth, After Oral Evaluation

D4355 40Full Mouth Debridement To Enable a Comprehensive Oral Evaluation And Diagnosis on a Subsequent Visit

D4381 35Localized Delivery Of Antimicrobial Agents Via Controlled Release Vehicle Into Diseased Crevicular Tissue, Per Tooth

TWUCurrent Dental Terminology ©2019 American Dental Association. All rights reserved. Page 3TWU 20 (06/19) TWU

Page 4: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

ADA Code

ADA Description

Member Pays $

OTHER PERIODONTAL SERVICES

D4910 30Periodontal Maintenance

D4920 0Unscheduled Dressing Change (By Someone Other Than Treating Dentist Or Their Staff)

COMPLETE DENTURES (including routine post delivery care)

D5110 225Complete Denture - Maxillary

D5120 225Complete Denture - Mandibular

D5130 250Immediate Denture - Maxillary

D5140 250Immediate Denture - MandibularPARTIAL DENTURES (including routine post-delivery care)

D5211 275Maxillary Partial Denture - Resin Base (Including Retentive/Clasping Materials, Rests And Teeth)

D5212 275Mandibular Partial Denture - Resin Base (Including Retentive/Clasping Materials, Rests And Teeth)

D5213 275Maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5214 275Mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth)

D5225 350Maxillary Partial Denture - Flexible Base (Including Any Clasps, Rests And Teeth)

D5226 350Mandibular Partial Denture - Flexible Base (Including Any Clasps, Rests And Teeth)

D5282 260Removable unilateral partial denture - one piece cast metal (including clasps and teeth), maxillary

D5283 260Removable unilateral partial denture - one piece cast metal (including clasps and teeth), mandibular

D5284 260Removable unilateral partial denture - one piece flexible base (including clasps and teeth) - per quadrant

D5286 260Removable unilateral partial denture - one piece resin (including clasps and teeth) - per quadrant

ADJUSTMENTS TO DENTURES

D5410 0Adjust Complete Denture - Maxillary

D5411 0Adjust Complete Denture - Mandibular

D5421 0Adjust Partial Denture - Maxillary

D5422 0Adjust Partial Denture - MandibularREPAIRS TO COMPLETE DENTURES

D5511 25Repair Broken Complete Denture Base, Mandibular

D5512 25Repair Broken Complete Denture Base, Maxillary

D5520 25Replace Missing Or Broken Teeth-Complete Denture (Each Tooth)

REPAIRS TO PARTIAL DENTURES

D5611 25Repair Resin Partial Denture Base, Mandibular

D5612 25Repair Resin Partial Denture Base, Maxillary

D5621 25Repair Cast Partial Framework, Mandibular

D5622 25Repair Cast Partial Framework, Maxillary

D5630 25Repair Or Replace Broken Retentive Clasping Materials - Per Tooth

D5640 25Replace Broken Teeth-Per Tooth

D5650 25Add Tooth To Existing Partial Denture

ADA Code

ADA Description

Member Pays $

REPAIRS TO PARTIAL DENTURES

D5660 25Add Clasp To Existing Partial Denture - Per Tooth

D5670 150Replace All Teeth And Acrylic On Cast Metal Framework (Maxillary)

D5671 150Replace All Teeth And Acrylic On Cast Metal Framework (Mandibular)

DENTURE REBASE PROCEDURES

D5710 55Rebase Complete Maxillary Denture

D5711 55Rebase Complete Mandibular Denture

D5720 55Rebase Maxillary Partial Denture

D5721 55Rebase Mandibular Partial DentureDENTURE RELINE PROCEDURES

D5730 35Reline Complete Maxillary Denture (Chairside)

D5731 35Reline Complete Mandibular Denture (Chairside)

D5740 35Reline Maxillary Partial Denture (Chairside)

D5741 35Reline Mandibular Partial Denture (Chairside)

D5750 55Reline Complete Maxillary Denture (Laboratory)

D5751 55Reline Complete Mandibular Denture (Laboratory)

D5760 55Reline Maxillary Partial Denture (Laboratory)

D5761 55Reline Mandibular Partial Denture (Laboratory)

D5820 55Interim Partial Denture (Maxillary)

D5821 55Interim Partial Denture (Mandibular)OTHER REMOVABLE PROSTHETIC SERVICES

D5850 10Tissue Conditioning, Maxillary

D5851 10Tissue Conditioning, MandibularFIXED PARTIAL DENTURE PONTICS

D6210 175Pontic-Cast High Noble Metal u

D6211 175Pontic-Cast Predominatly Base Metal

D6212 175Pontic-Cast Noble Metal u

D6214 175Pontic - titanium and titanium alloys

D6240 175Pontic-Porcelain Fused To High Noble Metal u

D6241 175Pontic-Porcelain Fused To Predominantly Base Metal

D6242 175Pontic-Porcelain Fused To Noble Metal u

D6243 175Pontic - porcelain fused to titanium and titanium alloys

D6245 225Pontic - Procelain/Ceramic

D6250 175Pontic, Resin With High Noble Metal u

D6251 175Pontic, Resin With Predominantly Base Metal

D6252 175Pontic, Resin With Noble Metal u

FIXED PARTIAL DENTURE RETAINTERS - INLAYS/ONLAYS

D6600 195Retainer Inlay - Porcelain/Ceramic, Two Surfaces

D6601 195Retainer Inlay - Porcelain/Ceramic, Three Or More Surfaces

D6602 150Retainer Inlay - Cast High Noble Metal, Two Surfaces

u

D6603 150Retainer Inlay - Cast High Noble Metal, Three Or More Surfaces

u

D6604 150Retainer Inlay - Cast Predominantly Base Metal, Two Surfaces

D6605 150Retainer Inlay - Cast Predominantly Base Metal, Three Or More Surfaces

TWUCurrent Dental Terminology ©2019 American Dental Association. All rights reserved. Page 4TWU 20 (06/19) TWU

Page 5: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

ADA Code

ADA Description

Member Pays $

FIXED PARTIAL DENTURE RETAINTERS - INLAYS/ONLAYS

D6606 150Retainer Inlay - Cast Noble Metal, Two Surfaces

u

D6607 150Retainer Inlay - Cast Noble Metal, Three Or More Surfaces

u

D6608 205Retainer Onlay - Porcelain/Ceramic, Two Surfaces

D6609 205Retainer Onlay - Porcelain/Ceramic, Three Or More Surfaces

D6610 150Retainer Onlay - Cast High Noble Metal, Two Surfaces

u

D6611 150Retainer Onlay - Cast High Noble Metal, Three Or More Surfaces

u

D6612 155Retainer Onlay - Cast Predominantly Base Metal, Two Surfaces

D6613 155Retainer Onlay - Cast Predominantly Base Metal, Three Or More Surfaces

D6614 150Retainer Onlay - Cast Noble Metal, Two Surfaces

u

D6615 150Retainer Onlay - Cast Noble Metal, Three Or More Surfaces

u

D6624 175Retainer Inlay - Titanium

D6634 175Retainer Onlay - TitaniumFIXED PARTIAL DENTURE RETAINERS - CROWNS

D6720 175Retainer Crown, Resin With High Noble Metal u

D6721 175Retainer Crown, Resin With Predominantly Base Metal

D6722 175Retainer Crown, Resin With Noble Metal u

D6740 225Retainer Crown - Porcelain/Ceramic

D6750 175Retainer Crown, Porcelain Fused To High Noble Metal

u

D6751 175Retainer Crown - Porcelain Fused To Predominantly Base Metal

D6752 175Retainer Crown, Porcelain Fused To Noble Metal

u

D6753 175Retainer crown - porcelain fused to titanium and titanium alloys

D6780 175Retainer Crown, 3/4 Cast High Noble Metal u

D6781 175Retainer Crown - 3/4 Cast Predominantly Base Metal

D6782 175Retainer Crown - 3/4 Cast Noble Metal u

D6783 175Retainer Crown - 3/4 Porcelain/Ceramic

D6784 175Retainer crown 3/4 - titanium and titanium alloys

D6790 175Retainer Crown, Full Cast High Noble Metal u

D6791 175Retainer Crown, Full Cast Predominantly Base Metal

D6792 175Retainer Crown, Full Cast Noble Metal u

D6794 175Retainer crown - titanium and titanium alloysOTHER FIXED PARTIAL DENTURE SERVICES

D6930 0Re‐Cement Or Re-Bond Fixed Partial Denture

D6940 115Stress BreakerEXTRACTIONS (includes local anesthesia, suturing, if needed, and

routine postoperative care)D7111 0Extraction, Coronal Remnants - Primary Tooth

D7140 0Extraction, Erupted Tooth Or Exposed Root (Elevation And/Or Forceps Removal)

ADA Code

ADA Description

Member Pays $

SURGICAL EXTRACTIONS (includes local anesthesia, suturing, if needed, and routine postoperative care)

D7210 25Extraction, Erupted Tooth Requiring Removal Of Bone And/Or Sectioning Of Tooth, And Including Elevation Of Mucoperiosteal Flap If Indicated

D7220 50Removal Of Impacted Tooth - Soft Tissue

D7230 75Removal Of Impacted Tooth - Partially Bony

D7240 115Removal Of Impacted Tooth - Completely Bony

D7241 135Removal Of Impacted Tooth - Completely Bony, With Unusual Surgical Complications

D7250 40Removal Of Residual Tooth Roots (Cutting Procedure)

D7251 115Coronectomy-Intentional Partial Tooth Removal

OTHER SURGICAL PROCEDURES

D7270 50Tooth Reimplantation And/Or Stabilization Of Accidentally Evulsed Or Displaced Tooth

D7280 85Exposure Of An Unerupted Tooth

D7282 90Mobilization Of Erupted Or Malpositioned Tooth To Aid Eruption

D7285 0Incisional Biopsy Of Oral Tissue‐Hard (Bone, Tooth)

D7286 0Incisional Biopsy Of Oral Tissue‐Soft

D7288 0Brush Biopsy - Transepithelial Sample Collection

ALVEOLOPLASTY (surgical preparation of ridge for dentures)

D7310 25Alveoloplasty In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant

D7311 10Alveoloplasty In Conjuction With Extractions - One To Three Teeth Or Tooth Spaces, Per Quandrant

D7320 40Alveoloplasty Not In Conjunction With Extractions - Four Or More Teeth Or Tooth Spaces, Per Quadrant

D7321 20Alveoloplasty Not In Conjunction With Extractions - One To Three Teeth Or Tooth Spaces, Per Quadrant

EXCISION OF BONE TISSUE

D7471 75Removal Of Lateral Exostosis (Maxilla Or Mandible)

D7472 50Removal Of Torus Palatinus

D7473 50Removal Of Torus Mandibularis

D7485 50Reduction Of Osseous TuberositySURGICAL INCISION

D7510 25Incision And Drainage Of Abscess - Intraoral Soft Tissue

D7511 25Incision And Drainage Of Abscess - Intraoral Soft Tissue - Complicated (Includes Drainage Of Multiple Fascial Spaces)

REPAIR OF TRAUMATIC WOUNDS

D7910 25Suture Of Recent Small Wounds Up To 5 CmOTHER REPAIR PROCEDURES

D7960 25Frenulectomy - Also Known As Frenectomy Or Frenotomy - Separate Procedure Not Incidental To Another Procedure

D7963 25Frenuloplasty

D7970 35Excision Of Hyperplastic Tissue - Per Arch

D7971 30Excision Pericoronal Gingival

D7972 100Surgical Reduction Of Fibrous Tuberosity

TWUCurrent Dental Terminology ©2019 American Dental Association. All rights reserved. Page 5TWU 20 (06/19) TWU

Page 6: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

ADA Code

ADA Description

Member Pays $

COMPREHENSIVE ORTHODONTIC TREATMENT

D8070 1895Comprehensive Orthodontic Treatment Of Transitional Dentition

D8080 1895Comprehensive Orthodontic Treatment Of Adolescent Dentition

D8090 1895Comprehensive Orthodontic Treatment Of Adult Dentition

OTHER ORTHODONTIC SERVICES

D8999 250Start-up Fee (including exam, beginning records, x-rays, tracing, photos, and models)

D8999 150Post treatment recordsCovered if required by your orthodontist.

D8680 300Orthodontic Retention (Removal Of Appliances, Construction And Placement Of Retainer(S)

UNCLASSIFIED TREATMENT

D9110 10Palliative (Emergency) Treatment Of Dental Pain, Minor Procedures

ANESTHESIA

D9211 0Regional Block Anesthesia

D9212 0Trigeminal Division Block Anesthesia

D9215 0Local Anesthesia In Conjunction With Operative Or Surgical Procedures

D9219 0Evaluation For Moderate Sedation, Deep Sedation Or General Anesthesia

D9222 78Deep Sedation/General Anesthesia - First 15 Minutes

D9223 78Deep Sedation/General Anesthesia - Each Subsequent 15 Mintue Increment

D9239 78Intravenous Moderate (Conscious) Sedation/Analgesia - First 15 Minutes

D9243 78Intravenous Moderate (Conscious) Sedation/Analgesia - Each Subsequent 15 Minute Increment

PROFESSIONAL CONSULTATION

D9310 0Consultation - Diagnostic Service Provided By Dentist Or Physician Other Than Requesting Dentist Or Physician

PROFESSIONAL VISITS

D9430 5Office Visit For Observation (During Regularly Scheduled Hours) - No Other Services Performed

D9440 35Office Visit After Regularly Scheduled Hours

D9450 0Case Presentation, Detailed And Extensive Treatment Planning

MISCELLANEOUS SERVICES

D9930 0Treatment Of Complications (Post-Surgical) Unusual Circumstances, By Report

D9943 21Occlusal Guard Adjustment

D9944 85Occlusal Guard - hard appliance, full arch

D9946 85Occlusal Guard - hard appliance, partial arch

D9951 30Occlusal Adjustment (Limited)

D9952 80Occlusal Adjustment (Complete)

D9972 125External Bleaching - Per Arch - Performed In Office

D9986 10Missed Appointment

D9987 10Cancelled appointment

D9990 0Certified translation or sign-language services - per visit

D9995 0Teledentistry - Synchronous; Real-Time Encounter

ADA Code

ADA Description

Member Pays $

MISCELLANEOUS SERVICES

D9996 0Teledentistry - Asynchronous; Information Stored and Forwarded to Dentist for Subsequent Review

D9997 0Dental care management - patients with special health care needs

FOOTNOTES

u The plan provides for the use of noble metals for inlays, onlays, crowns and bridges. When high noble metal is used, the Covered Person must pay the Copayment for the inlay, onlay, crown or bridge and an added charge equal to the actual laboratory cost of the high noble metal not to exceed $150.

TWUCurrent Dental Terminology ©2019 American Dental Association. All rights reserved. Page 6TWU 20 (06/19) TWU

Page 7: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS PDO

TEXASBEXAR County

SAN ANTONIO - 78216General Dentist

JOHNSON, ERIC A., DDS13487 BLANCO RD (210) 492-0631

Provider ID: 000805927 NPI Number: 1669586509

SAN ANTONIO - 78229General Dentist

CUEVAS, SIMONA, DDS4455 MEDICAL DR (210) 692-0153

Provider ID: 000970251 NPI Number: 1841516382

BRAZORIA CountyPEARLAND - 77581

Multi-Specialty

LALJI DENTAL PC1921 N MAIN ST STE 115 (713) 330-7700

Provider ID: 003481561 NPI Number: 1497890230

PEARLAND - 77584General Dentist

CASTLE DENTAL - PEARLAND10645 BROADWAY ST STE 102 (713) 436-9416

Provider ID: 001738455 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL11302 BROADWAY ST STE 104 (281) 416-5844

Provider ID: 002669579 NPI Number: 1386939213

COLLIN CountyALLEN - 75013General Dentist

MONARCH DENTAL - ALLEN204 CENTRAL EXPY S STE 59 (972) 649-0039

Provider ID: 002691466 NPI Number: 1639249303

MCKINNEY - 75070General Dentist

MONARCH DENTAL - MCKINNEY1720 N CENTRAL EXPY STE 130 (972) 547-6033

Provider ID: 001746871 NPI Number: 1639249303

MONARCH DENTAL - MCKINNEY/CUSTER8910 STATE HIGHWAY 121 STE 210 (214) 383-7676

Provider ID: 001683096 NPI Number: 1639249303

PLANO - 75093General Dentist

MONARCH DENTAL - N PLANO/PRESTON3516 PRESTON RD STE 600 (972) 612-0553

Provider ID: 001682289 NPI Number: 1639249303

DALLAS CountyCARROLLTON - 75006

General Dentist

MONARCH DENTAL - CARROLLTON2540 OLD DENTON RD STE 188 (972) 446-1211

Provider ID: 001683105 NPI Number: 1639249303

CEDAR HILL - 75104General Dentist

MONARCH DENTAL - CEDAR HILL420 E PLEASANT RUN RD STE 390 (469) 272-9333

Provider ID: 001696169 NPI Number: 1639249303

DALLAS - 75206General Dentist

MONARCH DENTAL - DALLAS/MOCKINGBIRD LANE5400 E MOCKINGBIRD LN STE 219 (214) 361-2227

Provider ID: 001683138 NPI Number: 1639249303

DALLAS - 75218General Dentist

MONARCH DENTAL - DALLAS/NORTH BUCKNER9440 GARLAND RD STE 230 (214) 660-0040

Provider ID: 000076900 NPI Number: 1639249303

DALLAS - 75219General Dentist

MONARCH DENTAL - OAK LAWN4140 LEMMON AVE STE 290 (214) 599-0778

Provider ID: 001682839 NPI Number: 1639249303

DALLAS - 75228General Dentist

MONARCH DENTAL - BUCKNER COMMONS9310 E RL THORNTON FWY STE 100 (214) 660-8997

Provider ID: 001836338 NPI Number: 1639249303

DALLAS - 75237General Dentist

MONARCH DENTAL - REDBIRD TOWERS3235 W CAMP WISDOM RD (214) 331-1131

Provider ID: 001683093 NPI Number: 1639249303

DALLAS - 75248General Dentist

MONARCH DENTAL - COIT/BELTLINE7989 BELT LINE RD STE 90 (972) 702-9017

Provider ID: 001580815 NPI Number: 1639249303

DALLAS - 75254General Dentist

MONARCH DENTAL - DALLAS/NORTH DALLAS PKW14400 DALLAS PKWY STE 200 (972) 720-8866

Provider ID: 001683118 NPI Number: 1639249303

DUNCANVILLE - 75116General Dentist

MONARCH DENTAL - DUNCANVILLE201 S CEDAR RIDGE DR (972) 709-9568

Provider ID: 001682283 NPI Number: 1639249303

GARLAND - 75041General Dentist

MONARCH DENTAL - GARLAND/CENTERVILLE1101 W CENTERVILLE RD STE 200 (972) 864-0695

Provider ID: 001682663 NPI Number: 1639249303

GARLAND - 75043General Dentist

SKY, WILLIAM J., DDS328 W INTERSTATE 30 (972) 226-0058

SPLanguage(s):

Provider ID: 000054565 NPI Number: 1720289341

GARLAND - 75044General Dentist

MONARCH DENTAL - GARLAND/BELT LINE RD3325 BELT LINE RD (972) 530-1222

Provider ID: 001683110 NPI Number: 1639249303

GRAND PRAIRIE - 75052General Dentist

MONARCH DENTAL - GRAND PRAIRIE594 W INTERSTATE 20 STE 205 (972) 264-6622

Provider ID: 001682281 NPI Number: 1639249303

IRVING - 75062General Dentist

MONARCH DENTAL - IRVING/AIRPORT FREEWAY3401 W AIRPORT FWY STE 206 (972) 256-6700

Provider ID: 001682665 NPI Number: 1639249303

IRVING - 75063General Dentist

HENEGAR, ANTHONY B., DDS7475 LAS COLINAS BLVD (972) 594-6915

Provider ID: 000848666 NPI Number: 1477586410

MESQUITE - 75150General Dentist

MONARCH DENTAL - MESQUITE/TOWNE CROSSING 3501 TOWNE CROSSING BLVD STE 180 (972) 270-6646

[

Provider ID: 001683156 NPI Number: 1639249303

ROWLETT - 75088General Dentist

MONARCH DENTAL - ROWLETT4305 LAKEVIEW PKWY STE 100 (972) 813-2500

Provider ID: 002103955 NPI Number: 1639249303

DENTON CountyDENTON - 76205

General Dentist

MONARCH DENTAL - DENTON2201 S INTERSTATE 35 E STE L21C (940) 387-1921

Provider ID: 001682662 NPI Number: 1639249303

DENTON - 76210General Dentist

MONARCH DENTAL - CORINTH7650 S INTERSTATE 35 E STE 152 (940) 497-2252

Provider ID: 001682279 NPI Number: 1639249303

FRISCO - 75034Multi-Specialty

MONARCH DENTAL - FRISCO5404 PRESTON RD STE 108 (972) 963-9104

Provider ID: 000583086 NPI Number: 1639249303

Page 1 of 5 July 2020Texas ConcordiaPLUS PDO

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 8: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS PDO

LEWISVILLE - 75056General Dentist

MARSH RIDGE FAMILY DENTAL & ORTHODONTICS4920 STATE HIGHWAY 121 STE 200 (972) 300-4155

Provider ID: 003028107 NPI Number: 1205387909

LEWISVILLE - 75067General Dentist

MONARCH DENTAL - LEWISVILLE1288 W MAIN ST STE 123 (972) 221-2220

Provider ID: 001682838 NPI Number: 1639249303

LITTLE ELM - 75068General Dentist

MONARCH DENTAL - LITTLE ELM2700 E ELDORADO PKWY STE 106 (972) 987-4944

Provider ID: 002092529 NPI Number: 1639249303

THE COLONY - 75056General Dentist

MONARCH DENTAL - JOSEY LANE4770 STATE HIGHWAY 121 STE 100 (972) 963-9900

Provider ID: 002140047 NPI Number: 1639249303

EL PASO CountyEL PASO - 79912

Multi-Specialty

MONARCH DENTAL7040 N MESA ST STE A (915) 833-1800

Provider ID: 001528539 NPI Number: 1720158496

ELLIS CountyRED OAK - 75154

General Dentist

MONARCH DENTAL - RED OAK109 E OVILLA RD STE 400 (972) 617-0208

Provider ID: 001683102 NPI Number: 1639249303

WAXAHACHIE - 75165General Dentist

MONARCH DENTAL - WAXAHACHIE895 N HIGHWAY 77 STE 400 (972) 937-3501

Provider ID: 001580726 NPI Number: 1639249303

FORT BEND CountyKATY - 77494Multi-Specialty

LOVETT DENTAL1998 KATY MILLS BLVD STE D (832) 437-6477

Provider ID: 002620808 NPI Number: 1982900270

MISSOURI CITY - 77459General Dentist

CASTLE DENTAL - MISSOURI CITY6261 HIGHWAY 6 STE 400 (281) 969-1536

Provider ID: 002585038 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL6245 HIGHWAY 6 STE 400 (281) 969-5099

Provider ID: 002669237 NPI Number: 1427330596

RICHMOND - 77406General Dentist

CASTLE DENTAL - GRAND PARKWAY5614 W GRAND PKWY S STE 120 (832) 586-7075

Provider ID: 001683191 NPI Number: 1457421125

ROSENBERG - 77471General Dentist

CASTLE DENTAL - ROSENBERG24601 SOUTHWEST FWY STE 200 (281) 239-2010

Provider ID: 002085871 NPI Number: 1457421125

STAFFORD - 77477General Dentist

SOUTHERN DENTAL12800 FOUNTAIN LAKE CIR (281) 277-1609

Provider ID: 000579909 NPI Number: 1497128458

SUGAR LAND - 77479General Dentist

CASTLE DENTAL - SUGAR LAND2565 TOWN CENTER BLVD N (281) 494-4449

Provider ID: 001465133 NPI Number: 1457421125

Multi-Specialty

GMS DENTAL CENTERS OF EXCELLENCE16126 SOUTHWEST FWY STE 200 (281) 207-2770

Provider ID: 002124638 NPI Number: 1003037243

ROYAL DENTAL226 FLUOR DANIEL DR (281) 242-2040

Provider ID: 001629949 NPI Number: 1497890230

GALVESTON CountyLEAGUE CITY - 77573

General Dentist

CASTLE DENTAL - LEAGUE CITY2925 GULF FWY S STE D (281) 337-0313

Provider ID: 001988400 NPI Number: 1457421125

HARRIS CountyBAYTOWN - 77521

Multi-Specialty

LOVETT DENTAL6502 GARTH RD STE 100 (281) 838-8400

Provider ID: 002695885 NPI Number: 1841568789

ROYAL DENTAL6644 GARTH RD (281) 839-0532

Provider ID: 000572389 NPI Number: 1497890230

CHANNELVIEW - 77530Multi-Specialty

GMS DENTAL CENTERS OF EXCELLENCE15201 EAST FWY STE 225 (281) 457-2847

Provider ID: 002124635 NPI Number: 1003037243

CROSBY - 77532Multi-Specialty

TRINITY CROSBY DENTAL PLLC14045 FM 2100 RD STE 250 (281) 328-2222

Provider ID: 002726983 NPI Number: 1881962546

CYPRESS - 77429General Dentist

CASTLE DENTAL - CYPRESS25823 HIGHWAY 290 STE E (281) 373-5559

Provider ID: 001993291 NPI Number: 1457421125

HOUSTON - 77005Multi-Specialty

LOVETT DENTAL6137 KIRBY DR (713) 490-8888

Provider ID: 001391255 NPI Number: 1417067968

HOUSTON - 77007Multi-Specialty

LOVETT DENTAL174 YALE ST STE 1200 (832) 767-2210

Provider ID: 002727911 NPI Number: 1629346440

SAWYER HIGHTS DENTAL PLLC1919 TAYLOR ST STE 3A (713) 863-1520

SPLanguage(s):

Provider ID: 003340605 NPI Number: 1376948026

HOUSTON - 77008General Dentist

CASTLE DENTAL - NORTH SHEPHERD961 N SHEPHERD DR (281) 661-3529

Provider ID: 001580816 NPI Number: 1639249303

Multi-Specialty

GMS DENTAL CENTERS OF EXCELLENCE1445 NORTH LOOP W STE 1000 (713) 861-3231

Provider ID: 002113805 NPI Number: 1003037243

SOUTHERN DENTAL W 19TH310 W 19TH ST (713) 869-4085

Provider ID: 000579793 NPI Number: 1598138547

HOUSTON - 77013Multi-Specialty

TRINITY HOUSTON EAST DENTAL PLLC503 MAXEY RD (832) 804-6055

Provider ID: 003014201 NPI Number: 1992147474

HOUSTON - 77015Multi-Specialty

ROYAL DENTAL E FRWY12960 EAST FWY (713) 453-3559

Provider ID: 000572961 NPI Number: 1497890230

HOUSTON - 77017Multi-Specialty

ROYAL DENTAL8449 GULF FWY STE C (713) 649-8590

Provider ID: 000331876 NPI Number: 1497890230

HOUSTON - 77020Multi-Specialty

AMJAD A SHEIKH DDS PA7008 LYONS AVE (713) 674-0811

[

Provider ID: 002726959 NPI Number: 1851566129

HOUSTON - 77021General Dentist

SOUTHERN DENTAL MLK5703 MARTIN LUTHER KING BLVD (713) 644-6595

Provider ID: 000580243 NPI Number: 1912370974

Page 2 of 5 July 2020Texas ConcordiaPLUS PDO

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 9: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS PDO

HOUSTON - 77022Multi-Specialty

LOVETT DENTAL4701 AIRLINE DR (713) 691-5551

Provider ID: 001934395 NPI Number: 1386865277

HOUSTON - 77027Multi-Specialty

SPLENDID DENTAL CARE & MY CHILDRENS DENTIS3991 RICHMOND AVE (713) 244-7797

Provider ID: 003814697 NPI Number: 1093256190

HOUSTON - 77035General Dentist

CASTLE DENTAL - POST OAK12341 MAIN ST (713) 729-9898

Provider ID: 001683201 NPI Number: 1457421125

HOUSTON - 77039Multi-Specialty

SHEIKH EASTEX DENTAL PA11939 EASTEX FWY STE I (281) 442-5500

Provider ID: 002726961 NPI Number: 1689994386

HOUSTON - 77040General Dentist

CASTLE DENTAL - NORTHWEST13486 NORTHWEST FWY (713) 460-4777

[

Provider ID: 001461908 NPI Number: 1457421125

HOUSTON - 77049Multi-Specialty

AMJAD A SHEIKH DDS PA5815 E SAM HOUSTON PKWY N STE C (281) 459-1555

Provider ID: 002726975 NPI Number: 1457618951

HOUSTON - 77054General Dentist

CASTLE DENTAL - FANNIN8132 KIRBY DR (713) 797-9041

[

Provider ID: 001544868 NPI Number: 1457421125

HOUSTON - 77055General Dentist

SOUTHERN DENTAL WIRT ROAD1459 WIRT RD (713) 932-1045

SPLanguage(s):

Provider ID: 000441045 NPI Number: 1023481082

HOUSTON - 77058General Dentist

CASTLE DENTAL - CLEARLAKE BAY AREA2321 BAY AREA BLVD (281) 480-9870

Provider ID: 001533290 NPI Number: 1457421125

HOUSTON - 77063General Dentist

CASTLE DENTAL - LAZY HOLLOW8571 WESTHEIMER RD STE C (713) 401-6230

Provider ID: 000833748 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL8570 WESTHEIMER RD (832) 242-2030

Provider ID: 001540065 NPI Number: 1720207897

HOUSTON - 77064Multi-Specialty

SOUTHERN DENTAL TOMBALL PKWY17776 STATE HIGHWAY 249 STE 20A (281) 469-0098

Provider ID: 000578710 NPI Number: 1013380070

HOUSTON - 77065General Dentist

CASTLE DENTAL - ELDRIDGE12246 FM 1960 RD W (281) 949-1001

[

Provider ID: 002100140 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL12711 FM 1960 RD W (281) 890-5002

Provider ID: 002045935 NPI Number: 1417118530

HOUSTON - 77069General Dentist

CASTLE DENTAL - CHAMPIONS5020 FM 1960 RD W STE B1 (281) 580-9058

Provider ID: 001529542 NPI Number: 1457421125

HOUSTON - 77070General Dentist

CASTLE DENTAL - COMPAQ21519 STATE HIGHWAY 249 STE H (281) 376-4848

Provider ID: 001580865 NPI Number: 1457421125

HOUSTON NORTHWEST DENTAL ASSOCIATES9631B FM 1960 RD W (281) 469-0589

EN, SPLanguage(s):

Provider ID: 000985998 NPI Number: 1982717922

Multi-Specialty

LOVETT DENTAL10123 LOUETTA RD STE 900 (832) 843-6776

Provider ID: 003065372 NPI Number: 1538588702

HOUSTON - 77074General Dentist

CHHEDA, HEMLATA N., DDS8191 SOUTHWEST FWY STE 111 (713) 988-3778

GU, HILanguage(s):

Provider ID: 000891448 NPI Number: 1467477935

HOUSTON - 77075General Dentist

CASTLE DENTAL - PEARLAND PARKWAY8501 S SAM HOUSTON PKWY E (713) 300-1470

Provider ID: 002526207 NPI Number: 1457421125

HOUSTON - 77082Multi-Specialty

LOVETT DENTAL3402 HIGHWAY 6 S STE C (281) 759-5900

Provider ID: 001762833 NPI Number: 1659592541

HOUSTON - 77083Multi-Specialty

ROYAL DENTAL HWY 6 SOUTH8145 HIGHWAY 6 S STE 130 (281) 498-8486

Provider ID: 000572482 NPI Number: 1497890230

HOUSTON - 77084General Dentist

CASTLE DENTAL - COPPERFIELD6831 HIGHWAY 6 N (281) 861-7054

Provider ID: 000582821 NPI Number: 1457421125

Multi-Specialty

ROYAL DENTAL HWY 6 NORTH5700 HIGHWAY 6 N STE 200 (281) 856-0999

EN, SPLanguage(s):

Provider ID: 000572425 NPI Number: 1497890230

HOUSTON - 77087Multi-Specialty

LOVETT DENTAL995 GULFGATE CENTER MALL (713) 847-8822

Provider ID: 001540053 NPI Number: 1568683456

HOUSTON - 77094Multi-Specialty

LOVETT DENTAL19961 KATY FWY (713) 244-7799

SPLanguage(s):

Provider ID: 003637789 NPI Number: 1568997021

HOUSTON - 77096Multi-Specialty

LOVETT DENTAL650 MEYERLAND PLAZA MALL (281) 974-3434

Provider ID: 003065395 NPI Number: 1598165094

HUMBLE - 77338General Dentist

CASTLE DENTAL - HUMBLE WEST9809 FM 1960 BYPASS RD W (281) 446-3855

Provider ID: 001581010 NPI Number: 1457421125

HUMBLE DENTAL ASSOCIATES9648 FM 1960 BYPASS RD W (281) 540-8100

Provider ID: 000778066 NPI Number: 1528171584

SOUTHERN DENTAL DEERBROOK MALL20131 HIGHWAY 59 N STE 1238 (281) 446-4237

Provider ID: 000581281 NPI Number: 1720462849

Multi-Specialty

LOVETT DENTAL20135 HIGHWAY 59 N STE A (281) 441-9000

[

Provider ID: 002141363 NPI Number: 1891920096

ROYAL DENTAL9952 FM 1960 BYPASS RD W (281) 358-6200

SPLanguage(s):

Provider ID: 002568528 NPI Number: 1497890230

HUMBLE - 77339General Dentist

BUTLER, KEVIN S., DDS3411 CEDAR KNOLLS DR (281) 358-7995

[

Provider ID: 000667045 NPI Number: 1245335462

HUMBLE - 77346Pediatric Dentist

SPLENDID DENTAL CARE7112 FM 1960 RD E (731) 244-7790

Provider ID: 003713376 NPI Number: 1396285110

Page 3 of 5 July 2020Texas ConcordiaPLUS PDO

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 10: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS PDO

KATY - 77449Multi-Specialty

SOUTHERN DENTAL ASSOCIATES1215 FRY RD STE D (281) 398-1986

SPLanguage(s):

Provider ID: 001313084 NPI Number: 1235502287

KATY - 77450General Dentist

CASTLE DENTAL - MASON462 S MASON RD STE 200 (281) 395-3555

Provider ID: 001683197 NPI Number: 1457421125

Multi-Specialty

GMS DENTAL CENTERS OF EXCELLENCE20065 KATY FWY (281) 994-5050

Provider ID: 002124632 NPI Number: 1003037243

PASADENA - 77504General Dentist

CASTLE DENTAL - PASADENA SPENCER3570 SPENCER HWY (713) 947-9800

[

Provider ID: 001512503 NPI Number: 1457421125

PASADENA - 77505General Dentist

CASTLE DENTAL - PASADENA FAIRMONT5106 FAIRMONT PKWY (281) 487-1202

Provider ID: 001683196 NPI Number: 1457421125

SOUTHERN DENTAL PASADENA7219 FAIRMONT PKWY STE 100 (281) 487-3975

Provider ID: 000581340 NPI Number: 1134592199

SPRING - 77379General Dentist

TRAN, KHANH, DDS18425 CHAMPION FOREST DR STE 220 (281) 320-8709

SP, VTLanguage(s):

Provider ID: 000565441 NPI Number: 1144664871

SPRING - 77388General Dentist

CASTLE DENTAL - SPRING FM 29202129 FM 2920 RD STE 240 (281) 661-3530

Provider ID: 001683153 NPI Number: 1457421125

SPRING - 77389Multi-Specialty

SPLENDID DENTAL CARE2156 SPRING STUEBNER RD UNIT 510 (713) 587-9996

SPLanguage(s):

Provider ID: 003713361 NPI Number: 1942712377

TOMBALL - 77377Multi-Specialty

TRINITY TOMBALL DENTAL PLLC14215 FM 2920 RD STE 103 (832) 698-2989

SPLanguage(s):

Provider ID: 002726994 NPI Number: 1851657795

WALLER - 77484Multi-Specialty

WALLER DENTAL ASSOCIATES PA31315 FM 2920 RD STE 16A (936) 372-2673

HI, PO, SPLanguage(s):

Provider ID: 002683282 NPI Number: 1104129279

WEBSTER - 77598General Dentist

CASTLE DENTAL - CLEARLAKE NASA1020 W NASA PKWY STE 250 (281) 332-1366

Provider ID: 001465157 NPI Number: 1457421125

SOUTHERN DENTAL WEBSTER1249 W BAY AREA BLVD (281) 332-6099

Provider ID: 000578693 NPI Number: 1639553746

Multi-Specialty

LOVETT DENTAL304 W BAY AREA BLVD STE 300 (832) 932-5584

Provider ID: 002150634 NPI Number: 1912234469

JEFFERSON CountyBEAUMONT - 77706

Multi-Specialty

LOVETT DENTAL4105 DOWLEN RD STE A (409) 924-8100

[

Provider ID: 001391222 NPI Number: 1194946087

JOHNSON CountyBURLESON - 76028

General Dentist

MONARCH DENTAL - BURLESON140 NW JOHN JONES DR STE 120 (817) 426-3355

Provider ID: 001829017 NPI Number: 1639249303

Multi-Specialty

GREAT EXPRESSIONS DENTAL CENTERS OF TEXAS225 SE JOHN JONES DR STE 103 (817) 447-3535

Provider ID: 002890192 NPI Number: 1932420221

LIBERTY CountyCLEVELAND - 77327

Multi-Specialty

TRINITY CLEVELAND DENTAL PLLC106 TRULY PLZ (281) 592-2202

Provider ID: 002726992 NPI Number: 1114295862

MIDLAND CountyMIDLAND - 79705

Multi-Specialty

MONARCH DENTAL3303 N MIDKIFF RD STE 112 (432) 699-6222

Provider ID: 001604532 NPI Number: 1366512030

MONTGOMERY CountyCONROE - 77304

General Dentist

CASTLE DENTAL - CONROE1410 N LOOP 336 W (936) 441-0481

Provider ID: 001533261 NPI Number: 1457421125

TRINITY CONROE DENTAL PLLC1304 W DAVIS ST STE A (936) 228-1764

Provider ID: 003823914 NPI Number: 1063923654

Multi-Specialty

LOVETT DENTAL1317 W DAVIS ST STE D (936) 760-2400

Provider ID: 002564671 NPI Number: 1477862209

MAGNOLIA - 77354General Dentist

CASTLE DENTAL - MAGNOLIA6209 FM 1488 RD STE A (281) 789-3055

[

Provider ID: 001580813 NPI Number: 1457421125

PORTER - 77365Multi-Specialty

NORTH EAST HOUSTON DENTAL SPECIALIST PLLC23762 HIGHWAY 59 (281) 306-5194

Provider ID: 004167209 NPI Number: 1801378849

SPRING - 77380General Dentist

CASTLE DENTAL - WOODLANDS25114 GROGANS MILL RD STE D (281) 296-7600

Provider ID: 001453947 NPI Number: 1457421125

WOODLAND DENTAL PARTNERS25300 BOROUGH PARK DR STE A (281) 296-0052

Provider ID: 001563843 NPI Number: 1407969009

THE WOODLANDS - 77380Multi-Specialty

WOODLAND DENTAL CARE341 SAWDUST RD (281) 362-0005

EN, SPLanguage(s):

Provider ID: 000986004 NPI Number: 1114030160

ROCKWALL CountyROCKWALL - 75087

General Dentist

MONARCH DENTAL - ROWLETT2306 GREENCREST BLVD (972) 722-5500

Provider ID: 001682288 NPI Number: 1639249303

TARRANT CountyARLINGTON - 76011

General Dentist

MONARCH DENTAL - ARLINGTON/NORTH COLLINS 1005 N COLLINS ST STE 100 (817) 795-4044

Provider ID: 001683160 NPI Number: 1639249303

ARLINGTON - 76016General Dentist

MONARCH DENTAL - ARLINGTON/PLEASANT RIDGE 5760 W PLEASANT RDG RD STE 110 (817) 561-9199

Provider ID: 001683141 NPI Number: 1639249303

ARLINGTON - 76017General Dentist

TURNER, CECIL FREDERICK, DDS4050 W INTERSTATE 20 (817) 563-1111

Provider ID: 000789141 NPI Number: 1144238304

Page 4 of 5 July 2020Texas ConcordiaPLUS PDO

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 11: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS PDO

BEDFORD - 76021General Dentist

MONARCH DENTAL - BEDFORD1717 AIRPORT FWY (817) 540-2223

Provider ID: 001683158 NPI Number: 1639249303

EULESS - 76039General Dentist

MONARCH DENTAL - EULESS SH1212721 STATE HIGHWAY 121 STE 300 (817) 786-3110

Provider ID: 001580817 NPI Number: 1639249303

FORT WORTH - 76104General Dentist

RUDDOCK, DWIGHT A., DDS719 HEMPHILL ST (817) 335-3806

ENLanguage(s):

Provider ID: 000789049 NPI Number: 1275546780

FORT WORTH - 76115General Dentist

MONARCH DENTAL - SEMINARY4200 SOUTH FWY STE 15 (817) 921-1554

Provider ID: 000868595 NPI Number: 1639249303

FORT WORTH - 76116General Dentist

MONARCH DENTAL - RIDGMAR1900 MALL CIR (817) 256-9823

Provider ID: 001683155 NPI Number: 1639249303

FORT WORTH - 76133General Dentist

MONARCH DENTAL - HULEN6261 GRANBURY RD (817) 346-9040

Provider ID: 001683098 NPI Number: 1639249303

FORT WORTH - 76135General Dentist

MONARCH DENTAL - LAKE WORTH6628 LAKE WORTH BLVD STE 200 (817) 238-7984

Provider ID: 001836341 NPI Number: 1639249303

HURST - 76053General Dentist

MONARCH DENTAL - HURST1101 MELBOURNE RD STE 2105 (817) 268-4867

Provider ID: 001434263 NPI Number: 1639249303

MANSFIELD - 76063General Dentist

MONARCH DENTAL - MANSFIELD101 W DEBBIE LN STE 106 (682) 518-5200

Provider ID: 001691732 NPI Number: 1639249303

Multi-Specialty

GREAT EXPRESSIONS DENTAL CENTERS OF TEXAS1551 HIGHWAY 287 N STE 411 (817) 453-6108

[

Provider ID: 002720498 NPI Number: 1811268659

NORTH RICHLAND HILLS - 76180General Dentist

MONARCH DENTAL - HILLTOP DR/RICHLAND HILLS6455 HILLTOP DR STE 114 (817) 577-3433

Provider ID: 001683108 NPI Number: 1639249303

NORTH RICHLAND HILLS - 76182General Dentist

MONARCH DENTAL - NORTH RICHLAND HILLS/DAVI8528 DAVIS BLVD STE 100 (817) 605-8067

Provider ID: 001757990 NPI Number: 1639249303

TRAVIS CountyAUSTIN - 78728

General Dentist

ADVANCED SMILE CENTER3407 WELLS BRANCH PKWY STE 700 (512) 244-7677

Provider ID: 000664735 NPI Number: 1104154251

Page 5 of 5 July 2020Texas ConcordiaPLUS PDO

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 12: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

Language Index

AF AFRIKAANS....... IN INDIAN....... TE TELUGU.......

AI ASIAN INDIAN....... IR IRANIAN....... TH THAI.......

AL ALBANIANS....... IT ITALIAN....... TK TURKISH.......

AM ARAMAIC....... JP JAPANESE....... TL TAMIL.......

AN ARMENIAN....... KA KANNADA....... TN TUNISIAN.......

AR ARABIC ....... KO KOREAN....... TO TOSK.......

AS ASSYRIAN....... KU KURDISH....... TU TURKMEN.......

AT AZERI TURKISH....... LA LATIN....... TW TAIWANESE.......

AU AZERBAIJANI TURKISH....... LB LEBANESE....... UK UKRAINIAN.......

AV AZERI....... LO LAOS....... UR URDU.......

AW AZARI....... LT LITHUANIAN....... UZ UZBEK.......

AZ AZERBAIJANI....... LV LATVIAN....... VS VISAYAN.......

BA BALOCHI....... MA MARATHI....... VT VIETNAMESE.......

BE BENGALI ....... MD MANDARIN....... YI YIDDISH.......

BL BULGARIAN....... MF MORE FOREIGN LANGUAGES....... YR YORUBA.......

BN BANTUSE....... MG MALAGASY.......

BR BERBERE....... MH MAHRATTI.......

BU BURMESE....... ML MALAYALAM.......

CA CASTILIAN....... MN MANIPURI.......

CL CATALAN ....... MY MALAY.......

CM CAMBODIAN....... NE NEPALISE .......

CN CHINESE....... NO NORWEGIAN.......

CO COORG....... PA PARATHI.......

CR CROATIAN....... PH PHILLIPINO.......

CT CANTONESE....... PI PASHTU.......

CZ CZECH....... PL POLISH.......

DA DARI....... PR PERSIAN .......

DN DANISH....... PS PASHAI.......

DT DUTCH....... PT PORTUGESE.......

EG EGYPTIAN....... PU PUNJABI.......

EI EAST INDIAN....... RM ROMANIAN .......

EN ENGLISH....... RS RUSSIAN.......

FA FARSI....... SA SWAMILIA.......

FI FINNISH....... SC SCOTTISH.......

FM FLEMISH ....... SE SETSWANA .......

FR FRENCH....... SG SINHALESE.......

FU FUKIEN CHINESE....... SH SHONA.......

GA GA....... SI SIGN LANGUAGE .......

GK GREEK....... SL SOUTH INDIAN.......

GL GAELIC....... SM SAMOAN.......

GR GERMAN....... SN SINDHI.......

GU GUJARATI....... SP SPANISH.......

HE HEBREW....... SR SERBIAN.......

HG HUNGARIAN....... SS SCANDANAVIAN.......

HI HINDI....... ST SANSKRIT.......

IB IBO....... SV SLOVAK.......

IC ICELANDIC....... SW SWEDISH.......

ID INDONESIAN/ORIYA ....... SY SYRIAN.......

IL ILOCANO....... TA PILIPINO/TAGALOG .......

Page 13: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS Specialists

TEXASBEXAR County

SAN ANTONIO - 78212Oral Surgery

GORDON, MATHEW C., DDS235 E HILDEBRAND AVE (210) 824-4501

Provider ID: 000975234 NPI Number: 1265591382

SAN ANTONIO - 78232Oral Surgery

KAERCHER, RAYMOND W., DDS14500 SAN PEDRO AVE STE 102 (210) 491-0015

SPLanguage(s):

Provider ID: 001564632 NPI Number: 1336122886

BRAZORIA CountyPEARLAND - 77581

Multi-Specialty

LALJI DENTAL PC1921 N MAIN ST STE 115 (713) 330-7700

Provider ID: 003481561 NPI Number: 1497890230

PEARLAND - 77584Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC10645 BROADWAY ST STE 102 (713) 436-9416

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC10645 BROADWAY ST STE 102 (713) 436-9416

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

CASTLE DENTAL10645 BROADWAY ST STE 102 (713) 436-9416

Provider ID: 000789287 NPI Number: 1457421125

Pediatric Dentist

MODERN DENTAL PROFESSIONALS HOUSTON PC10645 BROADWAY ST STE 102 (713) 436-9416

Provider ID: 001533221 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC10645 BROADWAY ST STE 102 (713) 436-9416

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL11302 BROADWAY ST STE 104 (281) 416-5844

Provider ID: 002669579 NPI Number: 1386939213

COLLIN CountyALLEN - 75013

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR204 CENTRAL EXPY S STE 59 (972) 649-0039

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR204 CENTRAL EXPY S STE 59 (972) 649-0039

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR204 CENTRAL EXPY S STE 59 (972) 649-0039

Provider ID: 001528076 NPI Number: 1639249303

MCKINNEY - 75070Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1720 N CENTRAL EXPY STE 130 (972) 547-6033

Provider ID: 001527588 NPI Number: 1639249303

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR8910 STATE HIGHWAY 121 STE 210 (214) 383-7676

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR8910 STATE HIGHWAY 121 STE 210 (214) 383-7676

Provider ID: 001528066 NPI Number: 1639249303

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1720 N CENTRAL EXPY STE 130 (972) 547-6033

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR8910 STATE HIGHWAY 121 STE 210 (214) 383-7676

Provider ID: 001661126 NPI Number: 1639249303

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1720 N CENTRAL EXPY STE 130 (972) 647-6033

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1720 N CENTRAL EXPY STE 130 (972) 547-6033

Provider ID: 001528076 NPI Number: 1639249303

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR8910 STATE HIGHWAY 121 STE 210 (214) 383-7676

Provider ID: 001528076 NPI Number: 1639249303

PLANO - 75093Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3516 PRESTON RD STE 600 (972) 612-0604

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3516 PRESTON RD STE 600 (972) 612-0553

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MONARCH DENTAL3516 PRESTON RD STE 600 (972) 612-0553

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3516 PRESTON RD STE 600 (972) 612-0553

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3516 PRESTON RD STE 600 (972) 612-0553

Provider ID: 001528076 NPI Number: 1639249303

DALLAS CountyCARROLLTON - 75006

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2540 OLD DENTON RD STE 188 (972) 446-1211

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2540 OLD DENTON RD STE 188 (972) 446-0742

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2540 OLD DENTON RD STE 188 (972) 446-0742

Provider ID: 001528076 NPI Number: 1639249303

CEDAR HILL - 75104Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR420 E PLEASANT RUN RD STE 390 (972) 764-2600

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR420 E PLEASANT RUN RD STE 390 (972) 764-2600

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR420 E PLEASANT RUN RD STE 390 (469) 272-9333

Provider ID: 001528076 NPI Number: 1639249303

COPPELL - 75019Oral Surgery

STEELE, JAMES D., DDS225 E STATE HIGHWAY 121 STE 150 (972) 315-3355

SPLanguage(s):

Provider ID: 000997310 NPI Number: 1053416610

DALLAS - 75206Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5400 E MOCKINGBIRD LN STE 219 (214) 361-2227

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5400 E MOCKINGBIRD LN STE 219 (214) 823-2618

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5400 E MOCKINGBIRD LN STE 219 (214) 361-2227

Provider ID: 001528076 NPI Number: 1639249303

DALLAS - 75218Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR9440 GARLAND RD STE 230 (214) 660-0040

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR9440 GARLAND RD STE 230 (214) 660-0040

Provider ID: 001528066 NPI Number: 1639249303

Page 1 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 14: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDALLAS - 75218 (continued)

Directory of Participating Dental Providers

ConcordiaPLUS Specialists

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR9440 GARLAND RD STE 230 (214) 660-0040

Provider ID: 001528076 NPI Number: 1639249303

DALLAS - 75219Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4140 LEMMON AVE STE 290 (214) 599-0778

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4140 LEMMON AVE STE 290 (214) 599-0728

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4140 LEMMON AVE STE 290 (214) 599-0779

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4140 LEMMON AVE STE 290 (214) 599-0778

Provider ID: 001528076 NPI Number: 1639249303

DALLAS - 75228Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR9310 E R L THORNTON FWY (214) 660-8997

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR9310 E R L THORNTON FWY STE 100 (214) 660-8997

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR9310 E R L THORNTON FWY STE 100 (214) 660-8997

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR9310 E R L THORNTON FWY STE 100 (214) 660-8997

Provider ID: 001528076 NPI Number: 1639249303

DALLAS - 75230Oral Surgery

MARSHALL JR., HAROLD O., DDS7777 FOREST LN STE B101 (972) 566-7622

SPLanguage(s):

Provider ID: 000589957 NPI Number: 1962483768

Periodontist

GOODMAN, CRAIG S., DDS5925 FOREST LN STE 310 (972) 233-1142

SPLanguage(s):

Provider ID: 000091501 NPI Number: 1285658005

DALLAS - 75237Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3235 W CAMP WISDOM RD (214) 331-1131

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3235 W CAMP WISDOM RD (214) 331-1131

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MONARCH DENTAL3235 W CAMP WISDOM RD (214) 331-1131

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3235 W CAMP WISDOM RD (214) 331-1131

Provider ID: 001528076 NPI Number: 1639249303

DALLAS - 75248Oral Surgery

MONARCH DENTAL7989 BELT LINE RD STE 90 (972) 702-9017

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR7989 BELT LINE RD STE 90 (972) 702-0007

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR7989 BELT LINE RD STE 90 (972) 702-0007

Provider ID: 001528076 NPI Number: 1639249303

DALLAS - 75254Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR14400 DALLAS PKWY STE 200 (972) 720-8866

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR14400 DALLAS PKWY STE 200 (972) 720-8866

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR14400 DALLAS PKWY STE 200 (972) 720-8866

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR14400 DALLAS PKWY STE 200 (972) 720-8866

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR14400 DALLAS PKWY STE 200 (972) 720-8866

Provider ID: 001528076 NPI Number: 1639249303

DUNCANVILLE - 75116Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR201 N CEDAR RIDGE DR STE 101 (972) 709-9568

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR201 S CEDAR RIDGE DR (972) 709-9568

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR201 S CEDAR RIDGE DR STE 101 (972) 709-9568

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR201 N CEDAR RIDGE DR STE 101 (972) 709-9568

Provider ID: 001528076 NPI Number: 1639249303

GARLAND - 75041Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1101 W CENTERVILLE RD STE 200 (972) 864-0695

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1101 W CENTERVILLE RD STE 200 (972) 864-0695

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1101 W CENTERVILLE RD STE 200 (972) 864-0695

Provider ID: 001528076 NPI Number: 1639249303

GARLAND - 75044Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3325 BELT LINE RD (972) 530-4885

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3325 BELT LINE RD (972) 530-4885

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3325 BELT LINE RD (972) 530-1222

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3325 BELT LINE RD (972) 530-4885

Provider ID: 001528076 NPI Number: 1639249303

GRAND PRAIRIE - 75052Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR594 W INTERSTATE 20 (972) 264-6507

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR594 W INTERSTATE 20 STE 205 (972) 264-6507

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR594 W INTERSTATE 20 (672) 264-6622

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR594 W INTERSTATE 20 (972) 264-6622

Provider ID: 001528076 NPI Number: 1639249303

Page 2 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 15: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS Specialists

IRVING - 75062Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3401 W AIRPORT FWY STE 206 (972) 256-6700

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3401 W AIRPORT FWY STE 206 (972) 256-7427

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3401 W AIRPORT FWY STE 206 (972) 256-6700

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3401 W AIRPORT FWY STE 206 (972) 256-7427

Provider ID: 001528076 NPI Number: 1639249303

IRVING - 75063Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR7620 N MACARTHUR BLVD (972) 831-0993

Provider ID: 001528076 NPI Number: 1639249303

MESQUITE - 75150Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3501 TOWNE CROSSING BLVD STE 180 (972) 270-6646

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3501 TOWNE CROSSING BLVD STE 180 (972) 270-6646

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3501 TOWNE CROSSING BLVD STE 180 (972) 270-6646

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR3501 TOWNE CROSSING BLVD STE 180 (972) 270-6646

Provider ID: 001528076 NPI Number: 1639249303

RICHARDSON - 75081Oral Surgery

HILL, STEPHEN C., DDS1001 BUCKINGHAM RD STE 106 (972) 644-8500

Provider ID: 000639088 NPI Number: 1588754915

ROWLETT - 75088Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4305 LAKEVIEW PKWY STE 100 (972) 412-6937

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4305 LAKEVIEW PKWY STE 100 (972) 813-2500

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4305 LAKEVIEW PKWY STE 100 (972) 535-1485

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4305 LAKEVIEW PKWY STE 100 (972) 813-2500

Provider ID: 001528076 NPI Number: 1639249303

DENTON CountyDENTON - 76205

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2201 S INTERSTATE 35 E STE L21C (940) 387-1921

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2201 S INTERSTATE 35 E STE L21C (940) 387-1921

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2201 S INTERSTATE 35 E STE L21 (940) 387-1921

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MONARCH DENTAL2201 S INTERSTATE 35 E STE L21C (940) 387-1921

Provider ID: 001528076 NPI Number: 1639249303

DENTON - 76210Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR7650 S INTERSTATE 35 E STE 152 (940) 497-2252

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR7650 S INTERSTATE 35 E STE 152 (940) 497-2252

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR7650 S INTERSTATE 35 E STE 152 (940) 497-2252

Provider ID: 001528076 NPI Number: 1639249303

FRISCO - 75034Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5404 PRESTON RD STE 108 (972) 963-9104

Provider ID: 001527588 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5404 PRESTON RD STE 108 (972) 963-9104

Provider ID: 001661126 NPI Number: 1639249303

LEWISVILLE - 75067Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1288 W MAIN ST STE 123 (972) 221-2220

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1288 W MAIN ST STE 123 (972) 436-4975

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1288 W MAIN ST STE 123 (972) 436-4975

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1288 W MAIN ST STE 123 (972) 436-4975

Provider ID: 001528076 NPI Number: 1639249303

LITTLE ELM - 75068Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2700 E ELDORADO PKWY STE 106 (972) 987-4944

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2700 E ELDORADO PKWY STE 106 (972) 987-4944

Provider ID: 001528076 NPI Number: 1639249303

THE COLONY - 75056Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4770 STATE HIGHWAY 121 STE 100 (972) 963-9900

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4770 STATE HIGHWAY 121 STE 100 (972) 963-9900

Provider ID: 001528066 NPI Number: 1639249303

EL PASO CountyEL PASO - 79912

Multi-Specialty

MONARCH DENTAL7040 N MESA ST STE A (915) 833-1800

Provider ID: 001528539 NPI Number: 1720158496

ELLIS CountyRED OAK - 75154

Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR109 E OVILLA RD STE 400 (972) 617-0208

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR109 E OVILLA RD STE 400 (972) 617-0208

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR109 E OVILLA RD STE 400 (972) 617-0208

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR109 E OVILLA RD STE 400 (972) 617-0208

Provider ID: 001661126 NPI Number: 1639249303

Page 3 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 16: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasRED OAK - 75154 (continued)

Directory of Participating Dental Providers

ConcordiaPLUS Specialists

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR109 W OVILLA RD STE 400 (972) 617-0208

Provider ID: 001528076 NPI Number: 1639249303

WAXAHACHIE - 75165Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR895 N HIGHWAY 77 STE 400 (972) 937-3501

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR895 N HIGHWAY 77 STE 400 (972) 937-2489

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR895 N HIGHWAY 77 STE 400 (972) 937-2489

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR895 N HIGHWAY 77 STE 400 (972) 937-3501

Provider ID: 001528076 NPI Number: 1639249303

FORT BEND CountyKATY - 77494

Oral Surgery

KATY PERIODONTOLOGY & ORAL SURGERY PLLC24437 KATY FWY STE 500 (281) 256-8400

Provider ID: 003142045 NPI Number: 1285039339

Multi-Specialty

CLEAR CHOICE ORTHODONTICS1260 PIN OAK RD STE 208 (281) 392-0888

Provider ID: 002055749 NPI Number: N/A

LOVETT DENTAL1998 KATY MILLS BLVD STE D (832) 437-6477

Provider ID: 002620808 NPI Number: 1982900270

MISSOURI CITY - 77459Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC6261 HIGHWAY 6 STE 300 (281) 969-1536

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC6261 HIGHWAY 6 STE 400 (281) 969-1536

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC6261 HIGHWAY 6 STE 300 (281) 969-1536

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL6245 HIGHWAY 6 STE 400 (281) 969-5099

Provider ID: 002669237 NPI Number: 1427330596

RICHMOND - 77406Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC5614 W GRAND PKWY S STE 120 (832) 586-7075

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC5614 W GRAND PKWY S STE 120 (832) 586-7075

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC5614 W GRAND PKWY S STE 120 (832) 586-7075

Provider ID: 000821580 NPI Number: 1457421125

ROSENBERG - 77471Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC24601 SOUTHWEST FWY STE 200 (281) 239-2010

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC24601 SOUTHWEST FWY STE 200 (281) 239-2010

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC24601 SOUTHWEST FWY STE 200 (281) 239-2010

Provider ID: 000821580 NPI Number: 1457421125

STAFFORD - 77477Multi-Specialty

SOUTHERN DENTAL SPECIALIST GROUP PLLC12800 FOUNTAIN LAKE CIR (281) 277-1609

Provider ID: 003414286 NPI Number: 1033580493

SUGAR LAND - 77478Oral Surgery

SUGARLAND ORAL AND MAXILLOFACIAL SURGERY15200 SOUTHWEST FWY STE 360 (281) 494-9433

CH, SPLanguage(s):

Provider ID: 001850223 NPI Number: N/A

Orthodontist

GREENBERG, LARRY Z., DDS15200 SOUTHWEST FWY STE 370 (281) 498-3700

Provider ID: 000343126 NPI Number: 1649457417

SUGAR LAND - 77479Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC2565 TOWN CENTER BLVD N (281) 494-4449

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC2565 TOWN CENTER BLVD N (281) 494-4449

Provider ID: 000789287 NPI Number: 1457421125

Pediatric Dentist

MODERN DENTAL PROFESSIONALS HOUSTON PC2565 TOWN CENTER BLVD N (281) 494-4449

Provider ID: 001533221 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC2565 TOWN CENTER BLVD N (281) 494-4449

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

GMS DENTAL CENTERS OF EXCELLENCE16126 SOUTHWEST FWY STE 200 (281) 207-2770

Provider ID: 002124638 NPI Number: 1003037243

ROYAL DENTAL226 FLUOR DANIEL DR (281) 242-2040

Provider ID: 001629949 NPI Number: 1497890230

GALVESTON CountyLEAGUE CITY - 77573

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC2925 GULF FWY S (281) 337-0313

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC2925 GULF FWY S (281) 337-0313

Provider ID: 000789287 NPI Number: 1457421125

Pediatric Dentist

MODERN DENTAL PROFESSIONALS HOUSTON PC2925 GULF FWY S STE D (281) 337-0313

Provider ID: 001533221 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC2925 GULF FWY S (281) 337-0313

Provider ID: 000821580 NPI Number: 1457421125

HARRIS CountyBAYTOWN - 77521

Multi-Specialty

LOVETT DENTAL6502 GARTH RD STE 100 (281) 838-8400

Provider ID: 002695885 NPI Number: 1841568789

ROYAL DENTAL6644 GARTH RD (281) 839-0532

Provider ID: 000572389 NPI Number: 1497890230

CHANNELVIEW - 77530Multi-Specialty

GMS DENTAL CENTERS OF EXCELLENCE15201 EAST FWY STE 225 (281) 457-2847

Provider ID: 002124635 NPI Number: 1003037243

CROSBY - 77532Multi-Specialty

TRINITY CROSBY DENTAL PLLC14045 FM 2100 RD STE 250 (281) 328-2222

Provider ID: 002726983 NPI Number: 1881962546

CYPRESS - 77429Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC25823 HIGHWAY 290 (281) 373-5559

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

CYPRESS ORAL & MAXILLOFACIAL SURGERY26321 NORTHWEST FWY STE 700 (281) 256-8400

Provider ID: 003090532 NPI Number: 1790047702

MODERN DENTAL PROFESSIONALS HOUSTON PC25823 HIGHWAY 290 (281) 373-3649

Provider ID: 000815603 NPI Number: 1457421125

Page 4 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 17: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasCYPRESS - 77429 (continued)

Directory of Participating Dental Providers

ConcordiaPLUS Specialists

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC25823 HIGHWAY 290 STE E (281) 373-5559

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC25823 HIGHWAY 290 (281) 373-3649

Provider ID: 000821580 NPI Number: 1457421125

HOUSTON - 77005Multi-Specialty

LOVETT DENTAL6137 KIRBY DR (713) 490-8888

Provider ID: 001391255 NPI Number: 1417067968

HOUSTON - 77007Multi-Specialty

LOVETT DENTAL174 YALE ST STE 1200 (832) 767-2210

Provider ID: 002727911 NPI Number: 1629346440

SAWYER HIGHTS DENTAL PLLC1919 TAYLOR ST STE 3A (713) 863-1520

SPLanguage(s):

Provider ID: 003340605 NPI Number: 1376948026

HOUSTON - 77008Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC961 N SHEPHERD DR (281) 661-3529

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC961 N SHEPHERD DR (281) 661-3529

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC961 N SHEPHERD DR (281) 661-3529

Provider ID: 000789287 NPI Number: 1457421125

Pediatric Dentist

MODERN DENTAL PROFESSIONALS HOUSTON PC961 N SHEPHERD DR (281) 661-3529

Provider ID: 001533221 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC961 N SHEPHERD DR (281) 661-3529

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

GMS DENTAL CENTERS OF EXCELLENCE1445 NORTH LOOP W STE 1000 (713) 861-3231

Provider ID: 002113805 NPI Number: 1003037243

SOUTHERN DENTAL SPECIALIST GROUP PLLC310 W 19TH ST (713) 861-6250

Provider ID: 003414272 NPI Number: 1033580493

SOUTHERN DENTAL W 19TH310 W 19TH ST (713) 869-4085

Provider ID: 000579793 NPI Number: 1598138547

HOUSTON - 77013Multi-Specialty

TRINITY HOUSTON EAST DENTAL PLLC503 MAXEY RD (832) 804-6055

Provider ID: 003014201 NPI Number: 1992147474

HOUSTON - 77015Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC12322 EAST FWY STE A (713) 453-8301

Provider ID: 000815603 NPI Number: 1457421125

Pediatric Dentist

MODERN DENTAL PROFESSIONALS HOUSTON PC12322 EAST FWY STE A (713) 453-8301

Provider ID: 001533221 NPI Number: 1457421125

Multi-Specialty

ROYAL DENTAL E FRWY12960 EAST FWY (713) 453-3559

Provider ID: 000572961 NPI Number: 1497890230

HOUSTON - 77017Multi-Specialty

ROYAL DENTAL8449 GULF FWY STE C (713) 649-8590

Provider ID: 000331876 NPI Number: 1497890230

HOUSTON - 77020Multi-Specialty

AMJAD A SHEIKH DDS PA7008 LYONS AVE (713) 674-0811

Provider ID: 002726959 NPI Number: 1851566129

HOUSTON - 77022Multi-Specialty

LOVETT DENTAL4701 AIRLINE DR (713) 691-5551

Provider ID: 001934395 NPI Number: 1386865277

HOUSTON - 77024Endodontist

ALAWADHI, SAUD A M, DDS791 TOWN AND COUNTRY BLVD STE 209 (713) 461-3636

AR, SPLanguage(s):

Provider ID: 001623335 NPI Number: 1073616272

HOUSTON - 77027Multi-Specialty

SPLENDID DENTAL CARE & MY CHILDRENS DENTIS3991 RICHMOND AVE (713) 244-7797

Provider ID: 003814697 NPI Number: 1093256190

HOUSTON - 77030Oral Surgery

REMEDIOS, BENITO L., DDS7505 MAIN ST STE 390 (713) 790-9474

SPLanguage(s):

Provider ID: 000970036 NPI Number: 1457361404

HOUSTON - 77035Oral Surgery

CASTLE DENTAL12341 MAIN ST (713) 729-9898

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC12341 MAIN ST (713) 729-9898

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC12341 MAIN ST (713) 729-9898

Provider ID: 000821580 NPI Number: 1457421125

HOUSTON - 77039Multi-Specialty

SHEIKH EASTEX DENTAL PA11939 EASTEX FWY STE I (281) 442-5500

Provider ID: 002726961 NPI Number: 1689994386

HOUSTON - 77040Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC13486 NORTHWEST FWY (713) 460-4777

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC13486 NORTHWEST FWY (713) 460-4777

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC13486 NORTHWEST FWY (713) 460-4777

Provider ID: 000821580 NPI Number: 1457421125

HOUSTON - 77044Oral Surgery

SUMMERWOOD ORAL SURGERY13057 W LAKE HOUSTON PKWY (832) 241-6100

Provider ID: 002880200 NPI Number: N/A

HOUSTON - 77049Multi-Specialty

AMJAD A SHEIKH DDS PA5815 E SAM HOUSTON PKWY N STE C (281) 459-1555

Provider ID: 002726975 NPI Number: 1457618951

HOUSTON - 77054Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC8132 KIRBY DR (713) 797-0267

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

HEATHER BROWN DDS PA2636 S LOOP W STE 100 (713) 665-4455

Provider ID: 002130634 NPI Number: 1477787406

MODERN DENTAL PROFESSIONALS HOUSTON PC8132 KIRBY DR (713) 797-0267

Provider ID: 000789287 NPI Number: 1457421125

Pediatric Dentist

MODERN DENTAL PROFESSIONALS HOUSTON PC8132 KIRBY DR (713) 797-9041

Provider ID: 001533221 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC8132 KIRBY DR (713) 797-0267

Provider ID: 000821580 NPI Number: 1457421125

Page 5 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 18: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasHOUSTON - 77054 (continued)

Directory of Participating Dental Providers

ConcordiaPLUS Specialists

Prosthodontist

MARRUFFO, JOANN P., DDS2600 S LOOP W STE 570 (713) 667-3300

SPLanguage(s):

Provider ID: 001899961 NPI Number: 1457496960

HOUSTON - 77058Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC2321 BAY AREA BLVD (281) 480-9870

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC2321 BAY AREA BLVD (281) 480-9870

Provider ID: 000789287 NPI Number: 1457421125

Pediatric Dentist

MODERN DENTAL PROFESSIONALS HOUSTON PC2321 BAY AREA BLVD (281) 480-9860

Provider ID: 001533221 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC2321 BAY AREA BLVD (281) 480-9870

Provider ID: 000821580 NPI Number: 1457421125

HOUSTON - 77063Endodontist

MAHNAZ MESSKOUB DDS MS PA9400 WESTHEIMER RD STE 1 (713) 932-7730

PR, SPLanguage(s):

Provider ID: 003696073 NPI Number: 1356564587

MODERN DENTAL PROFESSIONALS HOUSTON PC8571 WESTHEIMER RD STE C (713) 401-6230

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC8571 WESTHEIMER RD STE C (713) 401-6230

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC8571 WESTHEIMER RD STE C (713) 401-6230

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC8571 WESTHEIMER RD STE C (713) 401-6230

Provider ID: 000821580 NPI Number: 1457421125

TEXAS PERIODONTAL ASSOC7500 SAN FELIPE ST STE 325 (713) 457-6351

SPLanguage(s):

Provider ID: 001304981 NPI Number: N/A

Multi-Specialty

LOVETT DENTAL8570 WESTHEIMER RD (832) 242-2030

Provider ID: 001540065 NPI Number: 1720207897

HOUSTON - 77064Multi-Specialty

SOUTHERN DENTAL SPECIALIST GROUP PLLC17776 STATE HIGHWAY 249 STE 20A (281) 469-0097

Provider ID: 003414256 NPI Number: 1033580493

HOUSTON - 77065Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC12246 FM 1960 RD W (281) 949-1001

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC12246 FM 1960 RD W (281) 949-1001

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC12246 FM 1960 RD W (281) 949-1001

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC12246 FM 1960 RD W (281) 949-1001

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL12711 FM 1960 RD W (281) 890-5002

Provider ID: 002045935 NPI Number: 1417118530

HOUSTON - 77069Endodontist

MONARCH DENTAL5020 FM 1960 RD W STE B1 (281) 580-9058

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC5020 FM 1960 RD W STE B1 (281) 580-9058

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

CRIST, MICHAEL A., DDS13303 CHAMPION FOREST DR STE 10 (281) 895-7600

Provider ID: 000074553 NPI Number: 1013928233

MODERN DENTAL PROFESSIONALS HOUSTON PC5020 FM 1960 RD W STE B1 (281) 580-9058

Provider ID: 000789287 NPI Number: 1457421125

Pediatric Dentist

CASTLE DENTAL5020 CYPRESS CREEK PKWY STE B1 (281) 583-0888

Provider ID: 001533221 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC5020 FM 1960 RD W STE B1 (281) 580-9058

Provider ID: 000821580 NPI Number: 1457421125

HOUSTON - 77070Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC21519 STATE HIGHWAY 249 STE H (281) 376-4848

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC21519 STATE HIGHWAY 249 STE H (281) 376-4848

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

DASTOOR, SAROSH F., DMD12850 JONES RD STE 104 (281) 890-4867

GULanguage(s):

Provider ID: 002110099 NPI Number: 1942331392

MODERN DENTAL PROFESSIONALS HOUSTON PC21519 STATE HIGHWAY 249 STE H (281) 376-4848

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL10123 LOUETTA RD STE 900 (832) 843-6776

Provider ID: 003065372 NPI Number: 1538588702

HOUSTON - 77075Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC8501 S SAM HOUSTON PKWY E (713) 300-1407

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC8501 S SAM HOUSTON PKWY E D-110 (713) 300-1470

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC8501 S SAM HOUSTON PKWY E (713) 300-1470

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC8501 S SAM HOUSTON PKWY E (713) 300-1470

Provider ID: 000821580 NPI Number: 1457421125

HOUSTON - 77079Periodontist

SORDELLI, ALDO E., DDS1035 DAIRY ASHFORD RD STE 234 (281) 759-2929

EN, SPLanguage(s):

Provider ID: 000924491 NPI Number: 1225167596

HOUSTON - 77082Multi-Specialty

LOVETT DENTAL3402 HIGHWAY 6 S STE C (281) 759-5900

Provider ID: 001762833 NPI Number: 1659592541

HOUSTON - 77083Multi-Specialty

ROYAL DENTAL HWY 6 SOUTH8145 HIGHWAY 6 S STE 130 (281) 498-8486

Provider ID: 000572482 NPI Number: 1497890230

HOUSTON - 77084Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC6831 HIGHWAY 6 N (281) 861-7054

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC6831 HIGHWAY 6 N (281) 861-7054

Provider ID: 000789287 NPI Number: 1457421125

Page 6 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 19: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasHOUSTON - 77084 (continued)

Directory of Participating Dental Providers

ConcordiaPLUS Specialists

Pediatric Dentist

MODERN DENTAL PROFESSIONALS HOUSTON PC6831 HIGHWAY 6 N (281) 861-7054

Provider ID: 001533221 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC6831 HIGHWAY 6 N (281) 861-7345

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

ROYAL DENTAL HWY 6 NORTH5700 HIGHWAY 6 N STE 200 (281) 856-0999

EN, SPLanguage(s):

Provider ID: 000572425 NPI Number: 1497890230

HOUSTON - 77087Multi-Specialty

LOVETT DENTAL995 GULFGATE CENTER MALL (713) 847-8822

Provider ID: 001540053 NPI Number: 1568683456

HOUSTON - 77090Multi-Specialty

CLEAR CHOICE ORTHODONTICS112 BAMMEL WESTFIELD RD (281) 587-4900

Provider ID: 002055752 NPI Number: N/A

HOUSTON - 77094Multi-Specialty

LOVETT DENTAL19961 KATY FWY (713) 244-7799

SPLanguage(s):

Provider ID: 003637789 NPI Number: 1568997021

HOUSTON - 77096Periodontist

MEYERLAND PERIODONTAL ASSOC PLLC9660 HILLCROFT ST STE 353 (713) 283-9776

Provider ID: 001449530 NPI Number: N/A

Multi-Specialty

LOVETT DENTAL650 MEYERLAND PLAZA MALL (281) 974-3434

Provider ID: 003065395 NPI Number: 1598165094

HUMBLE - 77338Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC9809 FM 1960 BYPASS RD W (281) 446-3855

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC9809 FM 1960 BYPASS RD W (281) 446-3855

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC9809 FM 1960 BYPASS RD W (281) 446-3855

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL20135 HIGHWAY 59 N STE A (281) 441-9000

Provider ID: 002141363 NPI Number: 1891920096

ROYAL DENTAL9952 FM 1960 BYPASS RD W (281) 358-6200

SPLanguage(s):

Provider ID: 002568528 NPI Number: 1497890230

SOUTHERN DENTAL SPECIALIST GROUP PLLC20131 HIGHWAY 59 N STE 1238 (281) 446-4237

Provider ID: 003414285 NPI Number: 1033580493

HUMBLE - 77346Pediatric Dentist

SPLENDID DENTAL CARE7112 FM 1960 RD E (731) 244-7790

Provider ID: 003713376 NPI Number: 1396285110

KATY - 77449Multi-Specialty

SOUTHERN DENTAL ASSOCIATES1215 FRY RD STE D (281) 398-1986

SPLanguage(s):

Provider ID: 001313084 NPI Number: 1235502287

SOUTHERN DENTAL SPECIALIST GROUP PLLC1215 FRY RD STE D (281) 398-4132

Provider ID: 003414279 NPI Number: 1033580493

KATY - 77450Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC462 S MASON RD STE 200 (281) 395-3555

Provider ID: 000815603 NPI Number: 1457421125

WIGGINS, RAYMOND L., DDS810 S MASON RD STE 301 (281) 395-1200

Provider ID: 001503549 NPI Number: 1942297510

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC462 S MASON RD STE 200 (281) 395-3555

Provider ID: 000789287 NPI Number: 1457421125

Pediatric Dentist

WONG, CHUN YIN, DMD20065 KATY FWY (281) 994-5050

SPLanguage(s):

Provider ID: 004373094 NPI Number: 1982130233

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC462 S MASON RD STE 200 (281) 395-3555

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

GMS DENTAL CENTERS OF EXCELLENCE20065 KATY FWY (281) 994-5050

Provider ID: 002124632 NPI Number: 1003037243

KINGWOOD - 77339Orthodontist

PAIGE, SEBASTIAN Z., DDS23900 HIGHWAY 59 N (281) 358-6580

Provider ID: 002887723 NPI Number: 1932495132

PASADENA - 77504Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC3570 SPENCER HWY (713) 947-9800

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC3570 SPENCER HWY (713) 947-9800

Provider ID: 000789287 NPI Number: 1457421125

PASADENA - 77505Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC5106 FAIRMONT PKWY (281) 487-1202

Provider ID: 001532983 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC5106 FAIRMONT PKWY (281) 487-1225

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

CASTLE DENTAL5106 FAIRMONT PKWY (281) 487-1202

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

SOUTHERN DENTAL SPECIALIST GROUP PLLC7219 FAIRMONT PKWY STE 100 (281) 487-0318

Provider ID: 003422114 NPI Number: 1033580493

SPRING - 77379Orthodontist

MOHR, BRIAN A., DDS7623 LOUETTA RD STE 101 (281) 376-9670

ENLanguage(s):

Provider ID: 000479054 NPI Number: 1750557864

SPRING - 77388Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC2129 FM 2920 RD STE 240 (210) 928-2814

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

HAIDER, ZANE K., DMD2540 FM 2920 RD STE H (281) 937-2540

GR, HI, SP, URLanguage(s):

Provider ID: 003487170 NPI Number: 1275960023

MODERN DENTAL PROFESSIONALS HOUSTON PC2129 FM 2920 RD STE 240 (281) 661-3530

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC2129 FM 2920 RD STE 240 (210) 928-2814

Provider ID: 000821580 NPI Number: 1457421125

SPRING - 77389Multi-Specialty

SPLENDID DENTAL CARE2156 SPRING STUEBNER RD UNIT 510 (713) 587-9996

SPLanguage(s):

Provider ID: 003713361 NPI Number: 1942712377

TOMBALL - 77377Multi-Specialty

TRINITY TOMBALL DENTAL PLLC14215 FM 2920 RD STE 103 (832) 698-2989

SPLanguage(s):

Provider ID: 002726994 NPI Number: 1851657795

Page 7 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 20: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS Specialists

WALLER - 77484Multi-Specialty

WALLER DENTAL ASSOCIATES PA31315 FM 2920 RD STE 16A (936) 372-2673

HI, PO, SPLanguage(s):

Provider ID: 002683282 NPI Number: 1104129279

WEBSTER - 77598Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC1020 W NASA PKWY STE 250 (281) 332-1366

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC1020 W NASA PKWY STE 250 (281) 332-1366

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC1020 W NASA PKWY STE 250 (281) 332-1366

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC1020 W NASA PKWY STE 250 (281) 332-1366

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL304 W BAY AREA BLVD STE 300 (832) 932-5584

Provider ID: 002150634 NPI Number: 1912234469

SOUTHERN DENTAL SPECIALIST GROUP PLLC1249 W BAY AREA BLVD (281) 554-6382

Provider ID: 003414277 NPI Number: 1033580493

SOUTHERN DENTAL WEBSTER1249 W BAY AREA BLVD (281) 332-6099

Provider ID: 000578693 NPI Number: 1639553746

JEFFERSON CountyBEAUMONT - 77706

Multi-Specialty

LOVETT DENTAL4105 DOWLEN RD STE A (409) 924-8100

Provider ID: 001391222 NPI Number: 1194946087

JOHNSON CountyBURLESON - 76028

Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR140 NW JOHN JONES DR STE 120 (817) 426-3355

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR140 NW JOHN JONES DR (817) 426-3355

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR140 NW JOHN JONES DR STE 120 (817) 426-3355

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR140 NW JOHN JONES DR STE 120 (817) 426-3355

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR140 NW JOHN JONES DR (817) 426-3355

Provider ID: 001528076 NPI Number: 1639249303

Multi-Specialty

GREAT EXPRESSIONS DENTAL CENTERS OF TEXAS225 SE JOHN JONES DR STE 103 (817) 447-3535

Provider ID: 002890192 NPI Number: 1932420221

LIBERTY CountyCLEVELAND - 77327

Multi-Specialty

TRINITY CLEVELAND DENTAL PLLC106 TRULY PLZ (281) 592-2202

Provider ID: 002726992 NPI Number: 1114295862

MCLENNAN CountyWACO - 76705Pediatric Dentist

FRANCIS, SUSAN G., DDS3200 BELLMEAD DR (254) 799-4000

Provider ID: 001365431 NPI Number: 1326125915

MIDLAND CountyMIDLAND - 79705

Multi-Specialty

MONARCH DENTAL3303 N MIDKIFF RD STE 112 (432) 699-6222

Provider ID: 001604532 NPI Number: 1366512030

MONTGOMERY CountyCONROE - 77304

Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC1410 N LOOP 336 W (936) 441-0481

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC1410A N LOOP 336 W (936) 441-0481

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

LEIKER, BRADLEY J., DDS1003 LONGMIRE RD (936) 756-1386

Provider ID: 000801504 NPI Number: 1235256579

MODERN DENTAL PROFESSIONALS HOUSTON PC1410 N LOOP 336 W (936) 441-0481

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC1410A N LOOP 336 W (936) 441-0481

Provider ID: 000821580 NPI Number: 1457421125

Multi-Specialty

LOVETT DENTAL1317 W DAVIS ST STE D (936) 760-2400

Provider ID: 002564671 NPI Number: 1477862209

CONROE - 77384Pediatric Dentist

ROJAS, LUZ M., DDS17450 ST LUKES WAY STE 260 (936) 231-8705

SPLanguage(s):

Provider ID: 002735674 NPI Number: 1437325891

MAGNOLIA - 77354Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC6209 FM 1488 RD STE A (281) 789-3055

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC6209 FM 1488 RD STE A (281) 789-3055

Provider ID: 000789287 NPI Number: 1457421125

MOURITSEN, DAVID A., DDS31311 FM 2978 RD STE 101 (281) 356-3636

SPLanguage(s):

Provider ID: 003375872 NPI Number: 1811239510

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC6209 FM 1488 RD STE A (210) 615-3626

Provider ID: 000821580 NPI Number: 1457421125

PORTER - 77365Periodontist

FARAJ, SAMER A., DDS23762 HIGHWAY 59 (281) 306-5194

Provider ID: 004167236 NPI Number: 1588006902

SPRING - 77380Endodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC25114 GROGANS MILL RD (281) 296-7600

Provider ID: 001532983 NPI Number: 1457421125

Oral Surgery

MODERN DENTAL PROFESSIONALS HOUSTON PC25114 GROGANS MILL RD (281) 296-7600

Provider ID: 000815603 NPI Number: 1457421125

Orthodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC25114 GROGANS MILL RD (281) 296-7600

Provider ID: 000789287 NPI Number: 1457421125

Periodontist

MODERN DENTAL PROFESSIONALS HOUSTON PC25114 GROGANS MILL RD (281) 296-7600

Provider ID: 000821580 NPI Number: 1457421125

SPRING - 77381Orthodontist

MARDAGA, WILLIAM J., DDS4850 W PANTHER CREEK DR STE 108 (281) 367-7775

Provider ID: 000135175 NPI Number: 1245329515

MOURITSEN, DAVID A., DDS4850 W PANTHER CREEK DR STE 108 (281) 367-7775

Provider ID: 003639476 NPI Number: 1811239510

Page 8 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 21: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasDirectory of Participating Dental Providers

ConcordiaPLUS Specialists

SPRING - 77386Orthodontist

MARDAGA, WILLIAM J., DDS2211 RAYFORD RD STE 117 (281) 367-2211

Provider ID: 002097643 NPI Number: 1245329515

MOURITSEN, DAVID A., DDS2211 RAYFORD RD STE 117 (281) 367-2211

SPLanguage(s):

Provider ID: 003375872 NPI Number: 1811239510

THE WOODLANDS - 77380Multi-Specialty

DENTAL SPECIALISTS OF THE WOODLANDS PLLC25300 BOROUGH PARK DR STE C (281) 296-7007

Provider ID: 003333354 NPI Number: 1578963518

THE WOODLANDS - 77382Orthodontist

FARLEY, NORMAN D., DDS8000 RESEARCH FOREST DR STE 150 (281) 292-4272

SPLanguage(s):

Provider ID: 000604368 NPI Number: 1174604748

Multi-Specialty

CLEAR CHOICE ORTHODONTICS10845 KUYKENDAHL RD STE 100 (281) 587-4900

SPLanguage(s):

Provider ID: 002060199 NPI Number: N/A

ROCKWALL CountyROCKWALL - 75087

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2306 GREENCREST BLVD (972) 722-5500

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2306 GREENCREST BLVD (972) 722-5500

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2306 GREENCREST BLVD (972) 722-5500

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2306 GREENCREST BLVD (972) 722-5500

Provider ID: 001528076 NPI Number: 1639249303

TARRANT CountyARLINGTON - 76011

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1005 N COLLINS ST STE 100 (817) 795-4044

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1005 N COLLINS ST STE 100 (817) 795-4044

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1005 N COLLINS ST STE 100 (817) 795-4044

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1005 N COLLINS ST STE 100 (817) 795-4044

Provider ID: 001528076 NPI Number: 1639249303

ARLINGTON - 76016Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5760 W PLEASANT RDG RD STE 110 (817) 561-9199

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5760 W PLEASANT RDG RD STE 110 (817) 561-9199

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5760 W PLEASANT RDG RD STE 110 (817) 561-9198

Provider ID: 001528066 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR5760 W PLEASANT RDG RD STE 110 (817) 561-9198

Provider ID: 001528076 NPI Number: 1639249303

ARLINGTON - 76017Orthodontist

WONG, DEBBY H., DMD4050 W INTERSTATE 20 (817) 563-1111

CNLanguage(s):

Provider ID: 002651998 NPI Number: 1992940076

BEDFORD - 76021Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1717 AIRPORT FWY (817) 540-2223

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1717 AIRPORT FWY (817) 540-2223

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1717 AIRPORT FWY (817) 540-2223

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1717 AIRPORT FWY (817) 540-2223

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1717 AIRPORT FWY (817) 540-2223

Provider ID: 001528076 NPI Number: 1639249303

EULESS - 76039Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2721 STATE HIGHWAY 121 STE 300 (817) 786-3110

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2721 STATE HIGHWAY 121 STE 300 (817) 786-3110

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2721 STATE HIGHWAY 121 STE 300 (817) 786-3110

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR2721 STATE HIGHWAY 121 STE 300 (817) 786-3110

Provider ID: 001528076 NPI Number: 1639249303

FORT WORTH - 76107Orthodontist

PAULUS, WILLIAM G., DDS4901 BYERS AVE (817) 738-2163

SPLanguage(s):

Provider ID: 000987614 NPI Number: 1700909819

Periodontist

DANIEL JR., BENGE R., DDS3600 HULEN ST STE C4 (817) 737-2594

SPLanguage(s):

Provider ID: 000452105 NPI Number: 1164611463

FORT WORTH - 76109Oral Surgery

NEILL, MAX G., DDS4421 OAK PARK LN STE 101 (817) 927-1818

EN, SP, VTLanguage(s):

Provider ID: 000464938 NPI Number: 1538156658

Pediatric Dentist

PREECE CHURCH AND ASSOCIATES PEDIATRIC DE5700 EDWARDS RANCH RD STE 100 (817) 292-2004

SPLanguage(s):

Provider ID: 001654209 NPI Number: 1043754740

PREECE, GEORGE S., DDS5700 EDWARDS RANCH RD STE 100 (817) 292-2004

SPLanguage(s):

Provider ID: 000800697 NPI Number: 1245251362

FORT WORTH - 76115Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4200 SOUTH FWY STE 15 (817) 921-1554

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4200 SOUTH FWY STE 15 (817) 921-1554

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4200 SOUTH FWY STE 15 (817) 921-1554

Provider ID: 001528066 NPI Number: 1639249303

Page 9 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 22: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

TexasFORT WORTH - 76115 (continued)

Directory of Participating Dental Providers

ConcordiaPLUS Specialists

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4200 SOUTH FWY STE 15 (817) 921-1554

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR4200 SOUTH FWY STE 15 (817) 921-1554

Provider ID: 001528076 NPI Number: 1639249303

FORT WORTH - 76116Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1900 MALL CIR (817) 377-2228

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1900 MALL CIR (817) 377-2228

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1900 MALL CIR (817) 377-2228

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1900 MALL CIR (817) 377-2228

Provider ID: 001528076 NPI Number: 1639249303

FORT WORTH - 76133Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6261 GRANBURY RD (817) 346-9040

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6261 GRANBURY RD (817) 346-9040

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6261 GRANBURY RD (817) 346-9040

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6261 GRANBURY RD (817) 346-9040

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6261 GRANBURY RD (817) 346-9040

Provider ID: 001528076 NPI Number: 1639249303

FORT WORTH - 76135Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6628 LAKE WORTH BLVD STE 200 (817) 238-7984

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6628 LAKE WORTH BLVD STE 200 (817) 238-7984

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6628 LAKE WORTH BLVD STE 200 (817) 238-7984

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6628 LAKE WORTH BLVD STE 200 (817) 238-7984

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6628 LAKE WORTH BLVD STE 200 (817) 238-7984

Provider ID: 001528076 NPI Number: 1639249303

GRAPEVINE - 76051Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR306 S PARK BLVD (817) 251-2688

Provider ID: 001661126 NPI Number: 1639249303

HURST - 76053Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1101 MELBOURNE RD STE 7002 (817) 268-4867

Provider ID: 001527588 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR1101 MELBOURNE RD STE 2105 (817) 268-4867

Provider ID: 001528076 NPI Number: 1639249303

KELLER - 76244Pediatric Dentist

PREECE CHURCH AND ASSOCIATES PEDIATRIC DE4100 HERITAGE TRACE PKWY STE 100 (817) 741-6100

Provider ID: 001986544 NPI Number: 1043754740

MANSFIELD - 76063Endodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR101 W DEBBIE LN STE 106 (817) 779-3104

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR101 W DEBBIE LN STE 106 (682) 518-5200

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR101 W DEBBIE LN STE 106 (682) 518-5200

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR101 W DEBBIE LN STE 106 (682) 518-5200

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR101 W DEBBIE LN STE 106 (682) 518-5200

Provider ID: 001528076 NPI Number: 1639249303

Multi-Specialty

GREAT EXPRESSIONS DENTAL CENTERS OF TEXAS1551 HIGHWAY 287 N STE 411 (817) 453-6108

Provider ID: 002720498 NPI Number: 1811268659

NORTH RICHLAND HILLS - 76180Endodontist

MONARCH DENTAL6455 HILLTOP DR STE 114 (817) 577-3433

Provider ID: 001528052 NPI Number: 1639249303

Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6455 HILLTOP DR STE 114 (817) 577-3433

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6455 HILLTOP DR STE 114 (817) 577-3433

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6455 HILLTOP DR STE 114 (817) 577-3433

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR6455 HILLTOP DR STE 114 (817) 577-3433

Provider ID: 001528076 NPI Number: 1639249303

NORTH RICHLAND HILLS - 76182Oral Surgery

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR8528 DAVIS BLVD (817) 605-8067

Provider ID: 001527588 NPI Number: 1639249303

Orthodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR8528 DAVIS BLVD (817) 605-8067

Provider ID: 001528066 NPI Number: 1639249303

Pediatric Dentist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR8528 DAVIS BLVD STE 100 (217) 605-8067

Provider ID: 001661126 NPI Number: 1639249303

Periodontist

MODERN DENTAL PROFESSIONAL DALLAS/FT WOR8528 DAVIS BLVD STE 100 (817) 605-8067

Provider ID: 001528076 NPI Number: 1639249303

TRAVIS CountyAUSTIN - 78756

Oral Surgery

HORNE, RONALD D., DDS4306 MEDICAL PKWY STE 2 (512) 454-6744

SPLanguage(s):

Provider ID: 000884400 NPI Number: 1013061902

WEBB CountyLAREDO - 78041

Oral Surgery

SALAZAR, ROLANDO, DDS6419 POLARIS DR STE A3 (956) 795-1010

SPLanguage(s):

Provider ID: 001560884 NPI Number: 1871623389

TREVINO, CESAR, DDS6419 POLARIS DR STE A3 (956) 795-1010

SPLanguage(s):

Provider ID: 001440639 NPI Number: 1811027428

Page 10 of 10 July 2020Texas ConcordiaPLUS Specialists

Currently not accepting new patients.

This list of dental providers is subject to change. To confirm provider participation, please contact United Concordia (1-866-357-3304) or the provider. You may access an online directory at www.unitedconcordia.com

[

Page 23: Concordia Plus Schedule of Benefits€¦ · D1553 Re-cement or re-bond bilateral space 5 maintainer - per quadrant D1556 Removal of fixed unilateral space maintainer - 10 per quadrant

Language Index

AF AFRIKAANS....... IN INDIAN....... TE TELUGU.......

AI ASIAN INDIAN....... IR IRANIAN....... TH THAI.......

AL ALBANIANS....... IT ITALIAN....... TK TURKISH.......

AM ARAMAIC....... JP JAPANESE....... TL TAMIL.......

AN ARMENIAN....... KA KANNADA....... TN TUNISIAN.......

AR ARABIC ....... KO KOREAN....... TO TOSK.......

AS ASSYRIAN....... KU KURDISH....... TU TURKMEN.......

AT AZERI TURKISH....... LA LATIN....... TW TAIWANESE.......

AU AZERBAIJANI TURKISH....... LB LEBANESE....... UK UKRAINIAN.......

AV AZERI....... LO LAOS....... UR URDU.......

AW AZARI....... LT LITHUANIAN....... UZ UZBEK.......

AZ AZERBAIJANI....... LV LATVIAN....... VS VISAYAN.......

BA BALOCHI....... MA MARATHI....... VT VIETNAMESE.......

BE BENGALI ....... MD MANDARIN....... YI YIDDISH.......

BL BULGARIAN....... MF MORE FOREIGN LANGUAGES....... YR YORUBA.......

BN BANTUSE....... MG MALAGASY.......

BR BERBERE....... MH MAHRATTI.......

BU BURMESE....... ML MALAYALAM.......

CA CASTILIAN....... MN MANIPURI.......

CL CATALAN ....... MY MALAY.......

CM CAMBODIAN....... NE NEPALISE .......

CN CHINESE....... NO NORWEGIAN.......

CO COORG....... PA PARATHI.......

CR CROATIAN....... PH PHILLIPINO.......

CT CANTONESE....... PI PASHTU.......

CZ CZECH....... PL POLISH.......

DA DARI....... PR PERSIAN .......

DN DANISH....... PS PASHAI.......

DT DUTCH....... PT PORTUGESE.......

EG EGYPTIAN....... PU PUNJABI.......

EI EAST INDIAN....... RM ROMANIAN .......

EN ENGLISH....... RS RUSSIAN.......

FA FARSI....... SA SWAMILIA.......

FI FINNISH....... SC SCOTTISH.......

FM FLEMISH ....... SE SETSWANA .......

FR FRENCH....... SG SINHALESE.......

FU FUKIEN CHINESE....... SH SHONA.......

GA GA....... SI SIGN LANGUAGE .......

GK GREEK....... SL SOUTH INDIAN.......

GL GAELIC....... SM SAMOAN.......

GR GERMAN....... SN SINDHI.......

GU GUJARATI....... SP SPANISH.......

HE HEBREW....... SR SERBIAN.......

HG HUNGARIAN....... SS SCANDANAVIAN.......

HI HINDI....... ST SANSKRIT.......

IB IBO....... SV SLOVAK.......

IC ICELANDIC....... SW SWEDISH.......

ID INDONESIAN/ORIYA ....... SY SYRIAN.......

IL ILOCANO....... TA PILIPINO/TAGALOG .......