Dental HMO This SafeGuard dental plan will provide you with excellent benefits and save you money on dental care. Care is provided through an extensive network of contracted general dentists and specialty care providers at fees considerably lower than you would pay without this plan. The co-payment for each covered procedure is listed in the Schedule of Benefits included here. About this plan... No waiting periods, claims forms, deductibles or calendar year maximums You and your enrolled dependents may each choose a different general dentist Emergency out-of-network coverage Benefits include many specialty procedures The Schedule of Benefits and the Exclusions and Limitations contained within this enrollment kit are provided to give you the details of your benefit plan. Also included is your Evidence of Coverage, which provides further information regarding plan benefits. Benefits provided by SafeGuard Health Plans, Inc.
With MetLife's recent acquisition of SafeGuard Health Enterprises Inc., SafeGuard Health Plans, Inc. is now par t of the MetLife family of Companies. SafeGuard has been a trusted provider of dental benefits for 30 years. Our continued success is due to excellent ser vice, quality products and the fact that, at SafeGuard, our members are our first priority. Member satisfaction is monitored to ensure we meet our goals and your expectations. This booklet contains impor tant information about your SafeGuard benefit plan including your Schedule of Benefits and Evidence of Coverage. You will receive an ID card after your enrollment has been processed; in the meantime, if you choose to enroll, you may use the temporar y card below after the ef fective date of the program. Dental Benefits Plan Temporary Identification Card PRINT NAME SIGNATURE This card is not required to obtain services
SafeGuard Network Dentists SafeGuard contracts with dentists who meet our credentialing standards. Each dentist is pre-screened and each office is thoroughly evaluated prior to being accepted into our network. Before you enroll... Select a general dentist from the Directory of SafeGuard Par ticipating Dentists You and each of your enrolled dependents may select different general dentists Online Dentist Listing The most current network information can be found in our online director y at www.safeguard.net. Click on Dental & Vision Directories Choose "Visitor" and then select Dental HMO and state. Select your plan from the scroll down menu (check the Schedule of Benefits in this booklet for the name of your plan). You will be able to search by city, county, zip code, or by a par ticular dentist's name. After enrollment To access the directory once you are enrolled, log in to our website and use your Family ID number, Group ID number, or social security number (Family and Group ID numbers are provided on your ID card). If you have any questions, you can call Customer Ser vice at 800.880.1800.
SCHEDULE OF BENEFITS DIRECT REFERRAL DENTAL PLAN SGC1011-TX This Schedule of Benefits lists the services available to you under your SafeGuard plan, as well as the co-payments associated with each procedure. There are other factors that impact how your plan works and those are included here in the Exclusions & Limitations. Specialty Care Information: During the course of treatment, your SafeGuard selected general dentist may recommend the services of a dentist whose practice is limited to specialty care. Your selected general dentist may refer you directly to a contracted SafeGuard specialty care provider; no referral or pre-authorization from SafeGuard is required. Benefits provided by SafeGuard Health Plans, Inc. Code Service Co-payment Diagnostic Treatment D0120 Periodic oral evaluation established patient $0 D0140 Limited oral evaluation problem focused $0 D0145 Oral evaluation for a patient under three years of age and counseling with primary caregiver $0 D0150 Comprehensive oral evaluation new or established patient $0 D0170 Re-evaluation limited, problem focused (established patient; not post-operative visit) $0 D0180 Comprehensive periodontal evaluation new or established patient $0 Office visit - per visit (including all fees for sterilization and/ or infection control) $0 Radiographs/Diagnostic Imaging (X-rays) D0210 Intraoral complete series (including bitewings) $0 D0220 Intraoral periapical first film $0 D0230 Intraoral periapical each additional film $0 D0240 Intraoral occlusal film $0 D0250 Extraoral first film $0 D0260 Extraoral each additional film $0 D0270 Bitewing single film $0 D0272 Bitewings two films $0 D0273 Bitewings three films $0 D0274 Bitewings four films $0 D0330 Panoramic film $0 D0350 Oral/facial photographic images $0 Tests and Examinations D0415 Collection of microorganisms for culture and sensitivity $0 D0425 Caries susceptibility tests $0 D0460 Pulp vitality tests $0 D0470 Diagnostic casts $0 SGC1011-SOB Customer Service (800) 880-1800 1/09
Code Service Co-payment Preventive Services Cleanings (prophylaxis) & fluoride treatments are limited to 2 every 12 months, unless medically necessary. Sealants: Plan benefit applies to primary and permanent molar teeth, within four (4) years or eruption, unless medically necessary. D1110 Prophylaxis adult $0 D1120 Prophylaxis child $0 D1203 Topical application of fluoride (prophylaxis not included) child $0 D1204 Topical application of fluoride (prophylaxis not included) adult $0 D1206 Topical fluoride varnish; therapeutic application for moderate to high caries risk patients $0 D1310 Nutritional counseling for control of dental disease $0 D1330 Oral hygiene instructions $0 D1351 Sealant per tooth $5 D1510 Space maintainer fixed unilateral $25 D1515 Space maintainer fixed bilateral $25 D1520 Space maintainer removable unilateral $35 D1525 Space maintainer removable bilateral $35 D1550 Recementation of space maintainer $5 D1555 Removal of fixed space maintainer $5 Restorative Treatment D2140 Amalgam one surface, primary or permanent $5 D2150 Amalgam two surfaces, primary or permanent $10 D2160 Amalgam three surfaces, primary or permanent $15 D2161 Amalgam four or more surfaces, primary or permanent $20 D2330 Resin-based composite one surface, anterior $5 D2331 Resin-based composite two surfaces, anterior $10 D2332 Resin-based composite three surfaces, anterior $15 D2335 Resin-based composite four or more surfaces or involving incisal angle (anterior) $20 D2390 Resin-based composite crown, anterior $35 D2391 Resin-based composite one surface, posterior $40 D2392 Resin-based composite two surfaces, posterior $60 D2393 Resin-based composite three surfaces, posterior $80 D2394 Resin-based composite four or more surfaces, posterior $80 Crowns Replacement limit 1 every 5 years. An additional charge will be applied for any procedure using noble or high noble metal. Cases involving 7 or more crowns in the same treatment plan require a $125 member fee per unit in addition to co-pay. $75 fee per crown unit above co-pay for porcelain on molars. D2510 Inlay metallic one surface $165 D2520 Inlay metallic two surfaces $165 D2530 Inlay metallic three or more surfaces $165 D2543 Onlay metallic three surfaces $185 D2544 Onlay metallic four or more surfaces $185 D2650 Inlay resin-based composite one surface $165 D2651 Inlay resin-based composite two surfaces $165 D2652 Inlay resin-based composite three or more surfaces $165 D2740 Crown porcelain/ceramic substrate $225 D2750 Crown porcelain fused to high noble metal $185 D2751 Crown porcelain fused to predominantly base metal $185 SGC1011-SOB Customer Service (800) 880-1800 1/09
Code Service Co-payment D2752 Crown porcelain fused to noble metal $185 D2780 Crown ¾ cast high noble metal $185 D2781 Crown ¾ cast predominantly base metal $185 D2782 Crown ¾ cast noble metal $185 D2790 Crown full cast high noble metal $185 D2791 Crown full cast predominantly base metal $185 D2792 Crown full cast noble metal $185 D2794 Crown titanium $185 D2910 Recement inlay, onlay, or partial coverage restoration $0 D2915 Recement cast or prefabricated post and core $0 D2920 Recement crown $0 D2930 Prefabricated stainless steel crown primary tooth $25 D2931 Prefabricated stainless steel crown permanent tooth $25 D2940 Sedative filling $0 D2950 Core buildup, including any pins $20 D2951 Pin retention per tooth, in addition to restoration $5 D2952 Post and core in addition to crown, indirectly fabricated $35 D2953 Each additional indirectly fabricated post same tooth $35 D2954 Prefabricated post and core in addition to crown $30 D2955 Post removal (not in conjunction with endodontic therapy) $10 D2957 Each additional prefabricated post same tooth $35 D2962 Labial veneer (porcelain laminate) laboratory $210 D2970 Temporary crown (fractured tooth) $0 Endodontics All procedures exclude final restoration. D3110 Pulp cap direct (excluding final restoration) $0 D3120 Pulp cap indirect (excluding final restoration) $0 D3220 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament $10 D3230 Pulpal therapy (resorbable filling) anterior, primary tooth (excluding final restoration) $30 D3240 Pulpal therapy (resorbable filling) posterior, primary tooth (excluding final restoration) $35 D3310 Anterior (excluding final restoration) per tooth $95 D3320 Bicuspid (excluding final restoration) per tooth $115 D3330 Molar (excluding final restoration) per tooth $162 D3332 Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth $105 D3346 Retreatment of previous root canal therapy anterior per tooth $135 D3347 Retreatment of previous root canal therapy bicuspid per tooth $175 D3348 Retreatment of previous root canal therapy molar per tooth $275 D3351 Apexification/recalcification initial visit (apical closure/calcific repair of perforations, root resorption, etc.) $0 D3352 Apexification/recalcification interim medication replacement (apical closure/calcific repair of perforations, root resorption, etc.) $0 D3353 Apexification/recalcification final visit (includes completed root canal therapy apical closure/calcific repair of perforations, root resorption, etc.) $0 D3410 Apicoectomy/periradicular surgery anterior $80 D3421 Apicoectomy/periradicular surgery bicuspid (first root) $80 D3425 Apicoectomy/periradicular surgery molar (first root) $80 D3426 Apicoectomy/periradicular surgery (each additional root) $80 D3430 Retrograde filling per root $20 D3450 Root amputation per root $95 D3920 Hemisection (including any root removal), not including root canal therapy $90 SGC1011-SOB Customer Service (800) 880-1800 1/09
Code Service Co-payment Periodontics Periodontal charting for treatment planning of periodontal disease is included in exam and covered at no charge. D4210 Gingivectomy or gingivoplasty four or more contiguous teeth or bounded teeth spaces per quadrant $90 D4211 Gingivectomy or gingivoplasty one to three contiguous teeth or bounded teeth spaces per quadrant $64 D4240 Gingival flap procedure, including root planing four or more contiguous teeth or bounded teeth spaces per quadrant $95 D4241 Gingival flap procedure, including root planing one to three contiguous teeth or bounded teeth spaces per quadrant $64 D4249 Clinical crown lengthening hard tissue $125 D4260 Osseous surgery (including flap entry and closure) four or more contiguous teeth or bounded teeth spaces per quadrant $110 D4261 Osseous surgery (including flap entry and closure) one to three contiguous teeth or bounded teeth spaces per quadrant $74 D4270 Pedicle soft tissue graft procedure $250 D4271 Free soft tissue graft procedure (including donor site surgery) $250 D4273 Subepithelial connective tissue graft procedures, per tooth $75 D4274 Distal or proximal wedge procedure (when not performed in conjunction with surgical procedures in the same anatomical area) $70 D4275 Soft tissue allograft $70 D4320 Provisional splinting intracoronal $20 D4321 Provisional splinting extracoronal $20 D4341 Periodontal scaling and root planing four or more teeth per quadrant $25 D4342 Periodontal scaling and root planing one to three teeth per quadrant $17 D4355 Full mouth debridement to enable comprehensive evaluation and diagnosis $40 D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $60 D4910 Periodontal maintenance (2 in a 12 month period) $50 Removable Prosthodontics Replacement limit 1 every 5 years. Relines are limited to 1 every 12 months. Includes up to 3 adjustments within 6 months of delivery. D5110 Complete denture maxillary $210 D5120 Complete denture mandibular $210 D5130 Immediate denture maxillary $225 D5140 Immediate denture mandibular $225 D5211 Maxillary partial denture resin base (including any conventional clasps, rests and teeth) $300 D5212 Mandibular partial denture resin base (including any conventional clasps, rests and teeth) $300 D5213 Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $260 D5214 Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests and teeth) $260 D5410 Adjust complete denture maxillary $0 D5411 Adjust complete denture mandibular $0 D5421 Adjust partial denture maxillary $0 D5422 Adjust partial denture mandibular $0 D5510 Repair broken complete denture base $25 D5520 Replace missing or broken teeth complete denture (each tooth) $19 D5610 Repair resin denture base $30 SGC1011-SOB Customer Service (800) 880-1800 1/09
Code Service Co-payment D5620 Repair cast framework $45 D5630 Repair or replace broken clasp $19 D5640 Replace broken teeth per tooth $19 D5650 Add tooth to existing partial denture $25 D5660 Add clasp to existing partial denture $35 D5670 Replace all teeth and acrylic on cast metal framework (maxillary) $225 D5671 Replace all teeth and acrylic on cast metal framework (mandibular) $225 D5710 Rebase complete maxillary denture $75 D5711 Rebase complete mandibular denture $75 D5720 Rebase maxillary partial denture $75 D5721 Rebase mandibular partial denture $75 D5730 Reline complete maxillary denture (chairside) $50 D5731 Reline complete mandibular denture (chairside) $50 D5740 Reline maxillary partial denture (chairside) $50 D5741 Reline mandibular partial denture (chairside) $50 D5750 Reline complete maxillary denture (laboratory) $50 D5751 Reline complete mandibular denture (laboratory) $50 D5760 Reline maxillary partial denture (laboratory) $50 D5761 Reline mandibular partial denture (laboratory) $50 D5820 Interim partial denture (maxillary) $45 D5821 Interim partial denture (mandibular) $45 D5850 Tissue conditioning, maxillary $25 D5851 Tissue conditioning, mandibular $25 D5899 Duplicate complete denture $195 Crowns/Fixed Bridges - Per Unit Replacement limit 1 every 5 years. An additional charge will be applied for any procedure using noble or high noble metal. Cases involving 7 or more crowns and/or fixed bridge units in the same treatment plan require a $125 member fee per unit in addition to co-pay. $75 fee per crown/bridge unit above co-pay for porcelain on molars. D6210 Pontic cast high noble metal $185 D6211 Pontic cast predominantly base metal $185 D6212 Pontic cast noble metal $185 D6214 Pontic titanium $185 D6240 Pontic porcelain fused to high noble metal $185 D6241 Pontic porcelain fused to predominantly base metal $185 D6242 Pontic porcelain fused to noble metal $185 D6250 Pontic resin with high noble metal $185 D6251 Pontic resin with predominantly base metal $185 D6252 Pontic resin with noble metal $185 D6720 Crown resin with high noble metal $185 D6721 Crown resin with predominantly base metal $185 D6722 Crown resin with noble metal $185 D6750 Crown porcelain fused to high noble metal $185 D6751 Crown porcelain fused to predominantly base metal $185 D6752 Crown porcelain fused to noble metal $185 D6780 Crown ¾ cast high noble metal $185 D6781 Crown ¾ cast predominantly base metal $185 D6782 Crown ¾ cast noble metal $185 D6790 Crown full cast high noble metal $185 D6791 Crown full cast predominantly base metal $185 D6792 Crown full cast noble metal $185 D6794 Crown titanium $185 D6930 Recement fixed partial denture $0 SGC1011-SOB Customer Service (800) 880-1800 1/09
Code Service Co-payment D6940 Stress breaker $35 D6950 Precision attachment $75 D6970 Post and core in addition to fixed partial denture retainer, indirectly fabricated $50 D6972 Prefabricated post and core in addition to fixed partial denture retainer $30 D6973 Core build up for retainer, including any pins $10 D6980 Fixed partial denture repair, by report $10 Oral Surgery Includes routine - post operative visits/treatment. Surgical removal of impacted teeth - (not covered unless pathology [disease] exists). Surgical removal of wisdom tooth/third molar for orthodontic reasons only is not covered. D7111 Extraction, coronal remnants deciduous tooth $10 D7140 Extraction, erupted tooth or exposed root (elevation and/or forceps removal) $0 D7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth $15 D7220 Removal of impacted tooth soft tissue $30 D7230 Removal of impacted tooth partially bony $50 D7240 Removal of impacted tooth completely bony $75 D7241 Removal of impacted tooth completely bony, with unusual surgical complications $130 D7250 Surgical removal of residual tooth roots (cutting procedure) $75 D7270 Tooth reimplantation and/or stabilization of accidentally evulsed or displaced tooth $0 D7280 Surgical access of an unerupted tooth $50 D7285 Biopsy of oral tissue hard (bone, tooth) $0 D7286 Biopsy of oral tissue soft $0 D7310 Alveoloplasty in conjunction with extractions four or more teeth or tooth spaces, per quadrant $35 D7311 Alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant $10 D7320 Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces, per quadrant $40 D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant $20 D7510 Incision and drainage of abscess intraoral soft tissue $26 D7520 Incision and drainage of abscess extraoral soft tissue $26 D7910 Suture of recent small wounds up to 5 cm $0 D7960 Frenulectomy (frenectomy or frenotomy) separate procedure $40 D7963 Frenuloplasty $40 D7970 Excision of hyperplastic tissue per arch $30 D7971 Excision of pericoronal gingiva $25 Orthodontics Benefits cover 24 months of usual & customary orthodontic treatment and 24 months of retention. D8020 Limited orthodontic treatment of the transitional dentition $725 D8030 Limited orthodontic treatment of the adolescent dentition $725 D8040 Limited orthodontic treatment of the adult dentition $725 D8070 Comprehensive orthodontic treatment of the transitional dentition (full treatment case - including fixed/removable appliances) $1,300 D8080 Comprehensive orthodontic treatment of the adolescent dentition (full treatment case - including fixed/removable appliances) $1,300 SGC1011-SOB Customer Service (800) 880-1800 1/09
Code Service Co-payment D8090 Comprehensive orthodontic treatment of the adult dentition (full treatment case - including fixed/removable appliances) $1,500 D8660 Pre-orthodontic treatment visit $0 D8670 Periodic orthodontic treatment visit (as part of contract) $0 D8680 Retention phase (including fee for fixed/removable retainers and monthly visits for 24 months) $0 D8693 Rebonding or recementing; and/or repair, as required, of fixed retainers $0 Orthodontic treatment plan and records (pre/post x-rays, photos, study models) $0 Adjunctive General Services D9110 Palliative (emergency) treatment of dental pain minor procedure $0 D9120 Fixed partial denture sectioning $0 D9211 Regional block anesthesia $0 D9212 Trigeminal division block anesthesia $0 D9215 Local anesthesia $0 D9230 Analgesia, anxiolysis, inhalation of nitrous oxide $0 D9241 Intravenous conscious sedation/analgesia first 30 minutes $45 D9242 Intravenous conscious sedation/analgesia each additional 15 minutes $25 D9310 Consultation diagnostic service provided by dentist or physician other than requesting dentist or physician $0 D9430 Office visit for observation (during regularly scheduled hours) no other services performed $0 D9440 Office visit after regularly scheduled hours $35 D9450 Case presentation, detailed and extensive treatment planning $0 D9630 Other drugs and/or medicaments, by report $15 D9910 Application of desensitizing medicament $0 D9951 Occlusal adjustment limited $0 D9952 Occlusal adjustment complete $50 Current Dental Terminology American Dental Association SGC1011-SOB Customer Service (800) 880-1800 1/09
Dental Terminology Definitions These definitions are designed to give you a layman s understanding of some dental terminology in order for you to better understand your plan; they are not full descriptions. Amalgam: Anterior: Bicuspid: Bridge: Crown: Endodontics: Oral Surgery: Orthodontics: Periodontics: Posterior: Primary Teeth: Prophylaxis: Prosthodontics: Quadrant: Resin-based Composite: A silver filling Teeth that are in the front of the mouth Most people have eight bicuspid teeth; they are located immediately preceding the molar teeth with two in each quadrant of the mouth. A replacement for one or more missing teeth that is permanently attached to the teeth adjacent to the empty space(s). A covering created to place over a tooth to strengthen and/or replace tooth structure. A crown can be made of different materials (noble, high noble), base metal, porcelain or porcelain and metal. Procedures that treat the nerve or the pulp of the tooth due to injury or infection. Surgery to remove teeth, reshape portions of the bone in the mouth, or biopsy suspect areas of the mouth. Braces and other procedures to straighten the teeth. Procedures related to treatment of the supporting structures of the teeth (gums, underlying bone). Teeth that set towards the back of the mouth, including molars and bicuspids (premolars). The first set of teeth ( baby teeth). Scaling and polishing of teeth by removal of the plaque above the gum line. The restoration of natural and/or the replacement of missing teeth with artificial substitutes. One of the four equal sections into which your mouth can be divided (some procedures like periodontics are done in quadrants). Tooth-colored (white) fillings SGC1011-SOB Customer Service (800) 880-1800 1/09
Exclusions and Limitations Exclusions 1. Services performed by a general dentist or dentist whose practice is limited to providing specialty care, not contracted with SafeGuard, without prior approval by SafeGuard (except for out of area emergency services). 2. Any procedures not specifically listed as a covered benefit in the Schedule of Benefits. 3. Dental procedures initiated and completed prior to the member s eligibility under this Plan or started after the member s termination from the Plan. 4. Any dental services, or appliances which are determined to be not reasonable and/ or necessary for maintaining or improving the member s dental health, as determined by the SafeGuard Selected General Dentist. 5. Dental procedures or services performed solely for cosmetic purposes or solely for appearance, unless otherwise specified as a covered service in the Schedule of Benefits. 6. Orthognathic surgery. 7. General anesthesia. 8. Any inpatient/outpatient hospital charges of any kind including dentist and/or physician charges, prescriptions or medications. 9. Replacement of dentures, crowns, appliances or bridgework that have been lost, stolen, or damaged due to abuse, misuse or neglect, unless otherwise specified as a covered service in the Schedule of Benefits. 10. Treatment of malignancies, cysts, or neoplasms. 11. Procedures, appliances, or restorations whose main purpose is to change the vertical dimension of occlusion, correct congenital, developmental, or medically induced dental disorders including, but not limited to treatment of myofunctional, myoskeletal, or temporomandibular joint disorders unless otherwise specified as an orthodontic benefit on the Schedule of Benefits. 12. Dental implants and services associated with the placement of implants, prosthodontic restoration of dental implants, and specialized implant maintenance services. 13. Dental services provided for or paid by a federal or state government agency or authority, political subdivision, or other public program other than Medicaid or Medicare. 14. Dental services required while serving in the Armed Forces of any country or international authority or relating to a declared or undeclared war or acts of war. 15. Services considered unnecessary or experimental in nature. 16. Dental procedures or appliances for minor tooth guidance or for the control of harmful habits such as thumb sucking and tongue thrusting. Limitations 1. Cleanings (prophylaxis) and fluoride treatments are limited to twice a year, unless medically necessary. 2. An additional charge will be applied for any procedure using noble or high noble metal. 3. Relines are limited to one every twelve (12) months. 4. Panoramic or intraoral complete series, including bitewings (full mouth) x-rays are limited to once every three (3) years, unless medically necessary. EL s - SGC1011-TX SGC1011-SOB Customer Service (800) 880-1800 1/09
Exclusions and Limitations 5. Dentures (full or partial): Replacement only after five (5) years have elapsed following any prior provision of such dentures under a SafeGuard Benefit Plan. Replacements will be a benefit only if the existing denture is unsatisfactory and can not be made satisfactory as determined by the SafeGuard contracted general dentist. 6. Sealants: Plan benefit applies to primary and permanent molar teeth, within four (4) years of eruption, unless medically necessary. 7. Replacement of any crowns or fixed bridges (per unit) are limited to once every five (5) years. 8. Cases involving seven (7) or more crowns and/or fixed bridge units in the same treatment plan require a $125 co-payment per unit in addition to co-payment for each crown/ bridge unit. 9. There is a $75 co-payment per crown/bridge unit in addition to regular co-payments for porcelain on molars. 10. Surgical removal of wisdom teeth/third molar for orthodontic reasons only is not a covered benefit. 11. Delivery of removable prosthodontics includes up to three (3) adjustments within six (6) months of delivery date of service. 12. Surgical removal of impacted teeth is not a covered benefit unless pathology [disease] exists. 13. The co-payments listed for endodontic procedures do not include the cost of final restoration. Orthodontic Exclusions and Limitations 1. Orthodontic treatment must be provided by a SafeGuard Selected General Dentist or contracted dentist whose practice is limited to providing Specialty Care in order for the co-payments listed in the Schedule of Benefits to apply. Plan benefits shall cover twenty-four (24) months of usual and customary orthodontic treatment and an additional twenty-four (24) months of retention. Treatment extending beyond such time periods will be subject to a per-office-visit charge of $25 dollars. 2. The following are not included as orthodontic benefits: A. Repair or replacement of lost or broken appliances; B. Retreatment of orthodontic cases; C. Interceptive orthodontics; D. Changes in treatment necessitated by an accident; E. Treatment involving: 1) Maxillo-facial surgery, myofunctional therapy, cleft palate, micrognathia, macroglossia; 2) Hormonal imbalances or other factors affecting growth or developmental abnormalities; 3) Treatment related to temporomandibular joint disorders; 4) Lingually placed direct bonded appliances and arch wires ( invisible braces ); 3. The retention phase of treatment shall include the construction, placement, and adjustment of retainers. EL s - SGC1011-TX SGC1011-SOB Customer Service (800) 880-1800 1/09
Directory of Participating Dentists - Dental HMO Angleton Dunn, Dr. Forrest Facility # 52191 Forrest M Dunn DDS 206 E Cedar (979) 849-3741 77515 Stewart, Dr. Charles Facility # 1214 Charles Stewart DDS 2228 N Downing (979) 849-3083 77515 Baytown Andress, Dr. Ronnie Facility # 6639 6644 Garth Rd (281) 839-0532 77521 Kunjumon, Dr. Agee Facility # 6639 6644 Garth Rd (281) 839-0532 77521 McParland, Dr. Patrick Facility # 6639 6644 Garth Rd (281) 839-0532 77521 Mehdizadeh, Dr. Pedram Facility # 6639 6644 Garth Rd (281) 839-0532 77521 Mehmood, Dr. Afifa Facility # 6639 6644 Garth Rd (281) 839-0532 77521 Tabrizi, Dr. Matt Facility # 2818 Matt T Tabrizi DDS 4310 Garth Rd (281) 838-8888 77521 Thompson, Dr. Junior Facility # 6639 6644 Garth Rd (281) 839-0532 77521 Beaumont Bibb, Dr. Melanie Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Bousigues, Dr. Samantha Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Chinchilla, Dr. Julio Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Copeland, Dr. Jeffrey Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Freeman, Dr. Larry Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Hamidi, Dr. Rosita Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Parikh, Dr. Purvi Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Scott, Dr. Barbara Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Tucker, Dr. Jess Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Wilson, Dr. Mark Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Ziegenbein, Dr. Kent Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Zilberman, Dr. Susanna Facility # 8687 - Beaumont 4105 Dowlen Rd # A (409) 924-8100 77706 Channelview Dinh, Dr. Christine Facility # 60257 G M S Dental - Channelview 15201 E Frwy # 225 (281) 457-2847 77530 Neagle, Dr. Jack Facility # 60257 G M S Dental - Channelview 15201 E Frwy # 225 (281) 457-2847 77530 Slutsky, Dr. Alan Facility # 60257 G M S Dental - Channelview 15201 E Frwy # 225 (281) 457-2847 77530 Stone, Dr. James Facility # 60257 G M S Dental - Channelview 15201 E Frwy # 225 (281) 457-2847 77530 Conroe Cerelli, Dr. Jason Facility # 7351 Conwood Dental Associates 27866 C I-45 N (281) 681-2700 77385 Hamburg, Dr. Allan Facility # 7351 Conwood Dental Associates 27866 C I-45 N (281) 681-2700 77385 Paluk, Dr. Sergio Facility # 7351 Conwood Dental Associates 27866 C I-45 N (281) 681-2700 77385 Smith, Dr. Darrell Facility # 6703 Monarch Dental - Conroe 1410 N Loop 336 W (936) 441-0481 77304 Facility # 6703 Monarch Dental - Conroe 1410 N Loop 336 W (936) 441-0481 77304 Cypress Daftarian, Dr. Samaneh Facility # 61841 Lifetime Dental 10750 Barker Cypress Rd # 111 (281) 213-8666 77433 Simpson, Dr. Felicia Facility # 62939 Cypress Mill Dental 14315 Cypress Rosehill # 150 (281) 373-4533 77429 Facility # 66276 Castle Dental - Cypress 25823 Highway 290 (281) 373-5559 77429 Deer Park Ramos Jr, Dr. Rodolfo Facility # 60806 Rudy Ramos DDS 2114 Ctr (281) 479-5373 77536 *Currently unable to accept new members. Visit our website at www.safeguard.net for the most up-to-date listings. Page: 1
Directory of Participating Dentists - Dental HMO Urrutia, Dr. Maria Facility # 60806 Rudy Ramos DDS 2114 Ctr (281) 479-5373 77536 Dickinson * Johnson Jr, Dr. George Facility # 6069 George Johnson DDS 2108 Fm 517 Rd # E (281) 337-3441 77539 Friendswood Saeedi, Dr. Behnaz Facility # 38563 Dental Gallery 102 W El Dorado Blvd # C-1 (281) 990-8448 77546 Houston Abraham, Dr. Asha Facility # 7059 Castle Dental - Inner Loop 5712 Kirby Dr (713) 521-3509 77005 Allen, Dr. Jeff Facility # 271 Thomas H Magzen DDS 11000 Fondren Rd # B 105 (713) 981-9513 77096 Anton, Dr. Christopher Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 * Banks, Dr. Glenn Facility # 60059 Unique Dental 5438 N Frwy (713) 697-9100 77076 Banks, Dr. Glenn Facility # 4091 Unique Dental 9733 Westheimer Rd (713) 952-6161 77042 Banks, Dr. Glenn Facility # 8212 Unique Dental 6608 Hwy 6 N # C (281) 550-0900 77084 Belcher, Dr. Sheila Facility # 60531 Marquette Dentistry 8323 S W Freeway # 610 (713) 777-9865 77074 Berry Brown, Dr. Anita Facility # 8496 Champions Dental Group 3648 F M 1960 Rd W # 112 (281) 586-9400 77068 Bibb, Dr. Melanie Facility # 59298 3402 Highway 6 S # C (281) 759-5900 77082 Bibb, Dr. Melanie Facility # 59295 995 Gulfgate Center Mall (713) 847-8822 77087 Bibb, Dr. Melanie Facility # 62734 6137 Kirby Dr (713) 490-8880 77005 Bibb, Dr. Melanie Facility # 59297 8570 Westheimer Rd (832) 242-2030 77063 Bibb, Dr. Melanie Facility # 62733 4701 Airline Dr (713) 691-5551 77022 Bousigues, Dr. Samantha Facility # 62733 4701 Airline Dr (713) 691-5551 77022 Bousigues, Dr. Samantha Facility # 59297 8570 Westheimer Rd (832) 242-2030 77063 Bousigues, Dr. Samantha Facility # 62734 6137 Kirby Dr (713) 490-8880 77005 Bousigues, Dr. Samantha Facility # 67394 12711 FM 1960 Rd W (281) 890-5002 77065 Bousigues, Dr. Samantha Facility # 59298 3402 Highway 6 S # C (281) 759-5900 77082 Bousigues, Dr. Samantha Facility # 59295 995 Gulfgate Center Mall (713) 847-8822 77087 Bradbury, Dr. Timothy Facility # 727 Timothy A Bradbury DDS 10550 W Bellfort St # 140 (281) 530-7330 77031 Brueggen, Dr. Harold Facility # 75 H Wayne Brueggen DDS 14626 Bellaire Blvd (281) 879-1786 77083 Burch, Dr. Stacie Facility # 2838 Southern Dental Willowbrook 17776 Tomball Pkwy # 20 A (713) 777-2777 77064 Cerelli, Dr. Jason Facility # 1450 Houston Northwest Dental Associates 9631 F M 1960 Rd W # B (281) 469-0589 77070 Charles, Dr. Michael Facility # 7636 Michael Charles DDS 2101 Crawford St # 308 (713) 651-3040 77002 Chau, Dr. Hung Facility # 60056 Sunshine Dental 3444 Ella Blvd # A (713) 681-0140 77018 Chheda, Dr. Hemlata Facility # 772 Hema Chheda DDS 8191 SW Frwy # 111 (713) 988-3778 77074 Childers, Dr. Blake Facility # 7038 Castle Dental - Champions 5020 FM 1960 Rd W (281) 580-9058 77069 Chin, Dr. Edwin Facility # 6406 Edwin Chin DDS 3010 Little York Rd (713) 574-5159 77093 Chinchilla, Dr. Julio Facility # 59298 3402 Highway 6 S # C (281) 759-5900 77082 Chinchilla, Dr. Julio Facility # 59295 995 Gulfgate Center Mall (713) 847-8822 77087 Chinchilla, Dr. Julio Facility # 62733 4701 Airline Dr (713) 691-5551 77022 Chinchilla, Dr. Julio Facility # 59297 8570 Westheimer Rd (832) 242-2030 77063 Chinchilla, Dr. Julio Facility # 67394 12711 FM 1960 Rd W (281) 890-5002 77065 *Currently unable to accept new members. Visit our website at www.safeguard.net for the most up-to-date listings. Page: 2
Directory of Participating Dentists - Dental HMO Chu, Dr. Dan Facility # 6776 Houston Cosmetic & Implant Dentistry 3730 Kirby Dr # 401 (713) 523-4243 77098 Chung, Dr. Deborah Facility # 2823 Southern Dental - Palm Center 5703 Martin Luther King Blvd (713) 777-2777 77021 Clark, Dr. Thomas Facility # 1115 Thomas Clark DDS 4402 Airline Dr (713) 691-1831 77022 Coleman, Dr. Arthur Facility # 6461 Arthur Coleman D D S & Associates 5445 Almeda Rd # 300 (713) 526-1777 77004 Convert, Dr. Anne Facility # 4147 Westwood Dental 5770 Hollister St # B (713) 460-2444 77040 Convert, Dr. Anne Facility # 4148 Westwood Dental 14039 Westhiemer Rd (281) 558-3384 77077 Convert, Dr. Anne Facility # 60842 Westwood Dental 1454 Campbell St # 200 (713) 722-8400 77055 Convert, Dr. Anne Facility # 4146 Westwood Dental 6601 S Braeswood Blvd (713) 773-3333 77096 Crabtree, Dr. Leonard Facility # 1074 Leonard E Crabtree DDS Inc 1011 Augusta Dr # 209 (713) 623-0700 77057 Culver, Dr. Sylvia Facility # 2838 Southern Dental Willowbrook 17776 Tomball Pkwy # 20 A (713) 777-2777 77064 Cutropia, Dr. Craig Facility # 7595 Monarch Dental - 290 W 34Th 5215 W 34th St # C (713) 957-0772 77092 Davis, Dr. Freddie Facility # 60167 Freddie Davis DDS 5534 Wayside (713) 676-1110 77028 Denena, Dr. Joseph Facility # 6058 Joseph F Denena DDS 10600 Fondren Rd # 212 (713) 771-6979 77096 Dinh, Dr. Christine Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 Dinh, Dr. Christine Facility # 68655 GMS Dental - Katy Fwy 11767 Katy Fwy # 505 (281) 679-9340 77079 Dinh, Dr. Christine Facility # 60258 G M S Dental - Astrodome 2201 W Holcombe Blvd # 220 (713) 664-3400 77030 Dinh, Dr. Christine Facility # 68657 GMS Dental-Dryden 1709 Dryden Rd # 1411 (713) 942-9821 77030 Doolen, Dr. Jason Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Doolen, Dr. Jason Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Esfandiari, Dr. Soroush Facility # 60057 Holcombe Dental Associates 2329 W Holcombe Blvd (713) 667-9311 77030 Etessami, Dr. Katayoun Facility # 62839 Castle Dental 6831 Hwy 6 N (281) 861-7054 77084 Farrell, Dr. Tim Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 Farrell, Dr. Wendy Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 Freeman, Dr. Larry Facility # 59295 995 Gulfgate Center Mall (713) 847-8822 77087 Freeman, Dr. Larry Facility # 59298 3402 Highway 6 S # C (281) 759-5900 77082 * Gan, Dr. Ay Mey Facility # 6051 Ay Mey Gan DDS 3801 Kirby Dr # 200 (713) 522-9499 77098 Ghattas, Dr. Nagy Facility # 60055 Immanuel Dental Care 1147 Clear Lake City Blvd (281) 286-5867 77062 Glasper, Dr. Voris Facility # 2821 Voris Glasper DDS 6418 Laura Koppe (713) 633-7360 77016 * Gomez Infante De Rom, Dr. Iracema Facility # 2836 Southern Dental Associates 9664 Mesa Rd (713) 631-6806 77078 Gomez Infante De Rom, Dr. Iracema Facility # 2834 Southern Dental - Heights 310 W 19th St (713) 861-6242 77008 Gonzalez, Dr. Hugo Facility # 29556 Bellaire Dental 6200 Bellaire Blvd # 1 (713) 771-1969 77081 * Goodall, Dr. June Facility # 3856 June Goodall DDS 11111 Katy Frwy # 1000 (713) 461-3200 77079 * Gutierrez, Dr. Jorge Facility # 68751 Clear Choice Orthodontics 112 Bammel Westfield Rd (281) 587-4900 77090 * Gutierrez, Dr. Jorge Facility # 68750 Clear Choice Orthodontics - Galleria 6100 Westheimer # 150 (281) 392-0888 77057 Hackett, Dr. Clifford Facility # 60166 Clifford J Hackett DDS 7324 SW Frwy # 885 (713) 266-1937 77074 Hamada, Dr. Raif Facility # 7052 Castle Dental - Northwest 13486 Northwest Fwy (713) 460-4777 77040 Hamada, Dr. Raif Facility # 7038 Castle Dental - Champions 5020 FM 1960 Rd W (281) 580-9058 77069 *Currently unable to accept new members. Visit our website at www.safeguard.net for the most up-to-date listings. Page: 3
Directory of Participating Dentists - Dental HMO Hamblen, Dr. Don Facility # 1634 Don K Hamblen DDS 6910 Bellaire Blvd # 17 (713) 771-5689 77074 Hamburg, Dr. Allan Facility # 1450 Houston Northwest Dental Associates 9631 F M 1960 Rd W # B (281) 469-0589 77070 Hamburg, Dr. Allan Facility # 8496 Champions Dental Group 3648 F M 1960 Rd W # 112 (281) 586-9400 77068 Hamburg, Dr. Allan Facility # 10163 Legacy Dental Care 955 Dairy Ashford # 107 (281) 531-7000 77079 Hamidi, Dr. Rosita Facility # 67394 12711 FM 1960 Rd W (281) 890-5002 77065 Hamidi, Dr. Rosita Facility # 59295 995 Gulfgate Center Mall (713) 847-8822 77087 Hamidi, Dr. Rosita Facility # 62734 6137 Kirby Dr (713) 490-8880 77005 Hamidi, Dr. Rosita Facility # 62733 4701 Airline Dr (713) 691-5551 77022 Hamidi, Dr. Rosita Facility # 59297 8570 Westheimer Rd (832) 242-2030 77063 Hamidi, Dr. Rosita Facility # 59298 3402 Highway 6 S # C (281) 759-5900 77082 Hamouie, Dr. Loma Facility # 3048 Miles of Smiles Inc 3055 Sage # 190 (713) 623-6622 77056 Hansen, Dr. Fred Facility # 7299 Fred M Hansen DDS 909 Frostwood # 160 (713) 461-6161 77024 Harrison Jr, Dr. Robert Facility # 2823 Southern Dental - Palm Center 5703 Martin Luther King Blvd (713) 777-2777 77021 * Herrington, Dr. Martha Jane Facility # 36204 Community Dental Care 8535 W Bellfort (713) 777-8999 77071 Higgins, Dr. Stephen Facility # 60406 Lockwood Dental 4315 Lockwood Dr # 3 (713) 678-8428 77026 Higgins, Dr. Stephen Facility # 2823 Southern Dental - Palm Center 5703 Martin Luther King Blvd (713) 777-2777 77021 Hilton, Dr. Ted Facility # 6014 Ted R Hilton DDS Inc 9137 Hilllcroft (713) 266-3030 77096 Huang, Dr. Pai Facility # 60842 Westwood Dental 1454 Campbell St # 200 (713) 722-8400 77055 Huang, Dr. Pai Facility # 4148 Westwood Dental 14039 Westhiemer Rd (281) 558-3384 77077 Huang, Dr. Pai Facility # 4146 Westwood Dental 6601 S Braeswood Blvd (713) 773-3333 77096 Huang, Dr. Pai Facility # 4147 Westwood Dental 5770 Hollister St # B (713) 460-2444 77040 Huynh, Dr. Dung Facility # 7038 Castle Dental - Champions 5020 FM 1960 Rd W (281) 580-9058 77069 Iwuala, Dr. Gloria Facility # 2834 Southern Dental - Heights 310 W 19th St (713) 861-6242 77008 Jackson, Dr. Tracie Facility # 7048 Castle Dental - East 13247 East Fwy (713) 451-8888 77015 * Jafari, Dr. Haleh Facility # 36204 Community Dental Care 8535 W Bellfort (713) 777-8999 77071 Jafferally, Dr. Akbar Facility # 1450 Houston Northwest Dental Associates 9631 F M 1960 Rd W # B (281) 469-0589 77070 Jamea, Dr. Shahrzad Facility # 11779 Uptown General & Cosmetic Dentistry 5373 W Alabama # 118 (713) 355-5555 77056 Jamea, Dr. Shahrzad Facility # 58821 Methodist Dental 13420 Tomball Pkwy # B (281) 272-0106 77086 James Jr, Dr. Lloyd Facility # 6084 Lloyd James DDS 918 Mercury Dr (713) 675-6011 77029 Johnson, Dr. John Facility # 3106 John A Johnson DDS 7151 Parker Rd (713) 633-3130 77016 Jones, Dr. David Facility # 62734 6137 Kirby Dr (713) 490-8880 77005 Jones, Dr. David Facility # 62733 4701 Airline Dr (713) 691-5551 77022 Kasamali, Dr. Jasmin Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Kasamali, Dr. Jasmin Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Kennedy, Dr. Ross Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 King, Dr. Kenneth Facility # 1426 Kenneth J King DDS 2815 Eastex Freeway (713) 223-8930 77026 *Currently unable to accept new members. Visit our website at www.safeguard.net for the most up-to-date listings. Page: 4
Directory of Participating Dentists - Dental HMO Koroni, Dr. Abdoul Facility # 7890 Gulf Family Dental 4023 Gulf St (713) 645-8822 77087 Kunjumon, Dr. Agee Facility # 54 12960 East Fwy (713) 453-3559 77015 Kunjumon, Dr. Agee Facility # 55010 8303 Gulf Fwy # 112 (713) 649-8590 77017 Kunjumon, Dr. Agee Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Kunjumon, Dr. Agee Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Kwak, Dr. Jae-Hyuck Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 Lalji, Dr. Ayeez Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Lalji, Dr. Ayeez Facility # 55010 8303 Gulf Fwy # 112 (713) 649-8590 77017 Lalji, Dr. Ayeez Facility # 54 12960 East Fwy (713) 453-3559 77015 Lalji, Dr. Ayeez Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 * Lee, Dr. Carl Facility # 30877 Carl E Lee DDS Pc 2000 Crawford # 1522 (713) 757-0048 77002 Levison, Dr. Jeonghee Facility # 3100 Universal Dental Clinic P A 209 E Crosstimbers (713) 692-1344 77022 Lewis, Dr. David Facility # 2839 Southern Dental Associates 1459 Wirt Rd (713) 777-2777 77055 * Lewis, Dr. David Facility # 2825 Southern Dental Associates 2500 Central Pkwy # P (713) 224-2671 77092 Lewis, Dr. David Facility # 2834 Southern Dental - Heights 310 W 19th St (713) 861-6242 77008 Lewis, Dr. David Facility # 2823 Southern Dental - Palm Center 5703 Martin Luther King Blvd (713) 777-2777 77021 Lewis, Dr. David Facility # 2838 Southern Dental Willowbrook 17776 Tomball Pkwy # 20 A (713) 777-2777 77064 Lewis, Dr. Michael Facility # 2839 Southern Dental Associates 1459 Wirt Rd (713) 777-2777 77055 * Little, Dr. Thomas Facility # 64938 Castle Dental - West 12520 Westheimer Rd (281) 679-8888 77077 Lu, Dr. Jason Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Magzen, Dr. Thomas Facility # 271 Thomas H Magzen DDS 11000 Fondren Rd # B 105 (713) 981-9513 77096 Mc Arthur, Dr. Wallace Facility # 59298 3402 Highway 6 S # C (281) 759-5900 77082 McParland, Dr. Patrick Facility # 55010 8303 Gulf Fwy # 112 (713) 649-8590 77017 McParland, Dr. Patrick Facility # 54 12960 East Fwy (713) 453-3559 77015 Mehdizadeh, Dr. Pedram Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Mehdizadeh, Dr. Pedram Facility # 54 12960 East Fwy (713) 453-3559 77015 Mehdizadeh, Dr. Pedram Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Mehdizadeh, Dr. Pedram Facility # 4229 Monarch Dental - Clear Lake 2321 Bay Area Blvd (281) 480-9870 77058 Mehdizadeh, Dr. Pedram Facility # 55010 8303 Gulf Fwy # 112 (713) 649-8590 77017 Mehmood, Dr. Afifa Facility # 54 12960 East Fwy (713) 453-3559 77015 Mehmood, Dr. Afifa Facility # 55010 8303 Gulf Fwy # 112 (713) 649-8590 77017 Mehmood, Dr. Afifa Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Mehmood, Dr. Afifa Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Meliza, Dr. Michael Facility # 2834 Southern Dental - Heights 310 W 19th St (713) 861-6242 77008 Mota, Dr. Iselsa Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Naraghi, Dr. Ahmad Facility # 4146 Westwood Dental 6601 S Braeswood Blvd (713) 773-3333 77096 Naraghi, Dr. Ahmad Facility # 4148 Westwood Dental 14039 Westhiemer Rd (281) 558-3384 77077 Naraghi, Dr. Ahmad Facility # 60842 Westwood Dental 1454 Campbell St # 200 (713) 722-8400 77055 *Currently unable to accept new members. Visit our website at www.safeguard.net for the most up-to-date listings. Page: 5
Directory of Participating Dentists - Dental HMO Naraghi, Dr. Ahmad Facility # 4147 Westwood Dental 5770 Hollister St # B (713) 460-2444 77040 Neagle, Dr. Jack Facility # 60258 G M S Dental - Astrodome 2201 W Holcombe Blvd # 220 (713) 664-3400 77030 Neagle, Dr. Jack Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 Nguyen, Dr. Huong Facility # 51596 Hi-Tech Dental Care 5716 Bellaire Blvd # B (713) 668-1600 77081 * Nguyen, Dr. Mai Facility # 60059 Unique Dental 5438 N Frwy (713) 697-9100 77076 Nguyen, Dr. Mai Facility # 8212 Unique Dental 6608 Hwy 6 N # C (281) 550-0900 77084 Nguyen, Dr. Mai Facility # 4091 Unique Dental 9733 Westheimer Rd (713) 952-6161 77042 Nickleberry, Dr. Tammeka Facility # 2834 Southern Dental - Heights 310 W 19th St (713) 861-6242 77008 Nugent, Dr. Michael Facility # 2834 Southern Dental - Heights 310 W 19th St (713) 861-6242 77008 Orlando, Dr. Joseph Facility # 329 Apex Dental Associates 909 Dairy Ashford # 210 (281) 497-4740 77079 Parikh, Dr. Purvi Facility # 59295 995 Gulfgate Center Mall (713) 847-8822 77087 Parikh, Dr. Purvi Facility # 59298 3402 Highway 6 S # C (281) 759-5900 77082 Parikh, Dr. Purvi Facility # 67394 12711 FM 1960 Rd W (281) 890-5002 77065 Parikh, Dr. Purvi Facility # 62734 6137 Kirby Dr (713) 490-8880 77005 Parikh, Dr. Purvi Facility # 62733 4701 Airline Dr (713) 691-5551 77022 Parikh, Dr. Purvi Facility # 59297 8570 Westheimer Rd (832) 242-2030 77063 Pate Jr, Dr. Melvin Facility # 36622 Castle Dental - Compaq 21519 Tomball Pkwy # H (281) 376-4848 77070 * Patel, Dr. Pravina Facility # 60295 Family Dental Center 5901 Hillcroft Ave # D 6 (713) 781-1170 77036 Perez, Dr. Jennifer Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Perez, Dr. Jennifer Facility # 54 12960 East Fwy (713) 453-3559 77015 Perez, Dr. Jennifer Facility # 55010 8303 Gulf Fwy # 112 (713) 649-8590 77017 Perez, Dr. Jennifer Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Pham, Dr. Hoa Facility # 67195 Accent Dental Care PA 10917 Scarsdale Blvd (281) 481-2234 77089 Pham, Dr. Phuong Facility # 7561 Monarch Dental - Main 12341 Main St (713) 729-9898 77035 Punch, Dr. Ronald Facility # 1203 Ronald C Punch DDS 9802 Homestead Rd (713) 631-0191 77016 Ramos Jr, Dr. Rodolfo Facility # 60841 Rudy Ramos DDS 9545 Katy Fwy # 125 (713) 973-9591 77024 Rangappa, Dr. Suman Facility # 7051 Castle Dental - South 7906 Gulf Fwy (713) 847-0800 77017 * Rassner, Dr. Michael Facility # 1602 Michael A Rassner DDS 2600 S Gessner # 414 (713) 789-8680 77063 Richardson, Dr. Lakendra Facility # 2823 Southern Dental - Palm Center 5703 Martin Luther King Blvd (713) 777-2777 77021 * Richardson, Dr. Lakendra Facility # 2836 Southern Dental Associates 9664 Mesa Rd (713) 631-6806 77078 Richardson, Dr. Lakendra Facility # 2838 Southern Dental Willowbrook 17776 Tomball Pkwy # 20 A (713) 777-2777 77064 * Richardson, Dr. Lakendra Facility # 2825 Southern Dental Associates 2500 Central Pkwy # P (713) 224-2671 77092 Richardson, Dr. Lakendra Facility # 2839 Southern Dental Associates 1459 Wirt Rd (713) 777-2777 77055 Richardson, Dr. Lakendra Facility # 2834 Southern Dental - Heights 310 W 19th St (713) 861-6242 77008 Rosenquist III, Dr. Edward Facility # 7593 Monarch Dental - Champions 6510 F M 1960 W (281) 583-0888 77069 Russey Jr, Dr. Edward Facility # 4148 Westwood Dental 14039 Westhiemer Rd (281) 558-3384 77077 Russey Jr, Dr. Edward Facility # 4147 Westwood Dental 5770 Hollister St # B (713) 460-2444 77040 Russey Jr, Dr. Edward Facility # 4146 Westwood Dental 6601 S Braeswood Blvd (713) 773-3333 77096 *Currently unable to accept new members. Visit our website at www.safeguard.net for the most up-to-date listings. Page: 6
Directory of Participating Dentists - Dental HMO Russey Jr, Dr. Edward Facility # 60842 Westwood Dental 1454 Campbell St # 200 (713) 722-8400 77055 Scott, Dr. Barbara Facility # 59298 3402 Highway 6 S # C (281) 759-5900 77082 Scott, Dr. Barbara Facility # 67394 12711 FM 1960 Rd W (281) 890-5002 77065 Scott, Dr. Barbara Facility # 62733 4701 Airline Dr (713) 691-5551 77022 Scott, Dr. Barbara Facility # 59297 8570 Westheimer Rd (832) 242-2030 77063 Scott, Dr. Barbara Facility # 59295 995 Gulfgate Center Mall (713) 847-8822 77087 Scott, Dr. Barbara Facility # 62734 6137 Kirby Dr (713) 490-8880 77005 Shah, Dr. Tara Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Shah, Dr. Tara Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Shanthagowda, Dr. Chaitra Facility # 4228 Monarch Dental - Gulf Gate 6888 Gulf Frwy # 610 (713) 643-0040 77087 Shanthagowda, Dr. Chaitra Facility # 7049 Monarch Dental - Post Oak 12520 Westheimer Rd (281) 679-8888 77077 Shirvani, Dr. Neelufar Facility # 730 5700 Highway 6 N # 200 (281) 856-0999 77084 Shirvani, Dr. Neelufar Facility # 177 8145 Hwy 6 S # 130 (281) 498-8486 77083 Shoaee, Dr. Ali Facility # 7037 Castle Dental - North 6500 North Fwy # 124 (713) 696-8111 77076 Simpson, Dr. Oliver Facility # 7053 Castle Dental - Katy 19961 Katy Fwy (281) 599-7700 77094 Slutsky, Dr. Alan Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 Slutsky, Dr. Alan Facility # 60258 G M S Dental - Astrodome 2201 W Holcombe Blvd # 220 (713) 664-3400 77030 Slutsky, Dr. Alan Facility # 68655 GMS Dental - Katy Fwy 11767 Katy Fwy # 505 (281) 679-9340 77079 Facility # 62839 Castle Dental 6831 Hwy 6 N (281) 861-7054 77084 Facility # 7595 Monarch Dental - 290 W 34Th 5215 W 34th St # C (713) 957-0772 77092 Facility # 7051 Castle Dental - South 7906 Gulf Fwy (713) 847-0800 77017 Facility # 7053 Castle Dental - Katy 19961 Katy Fwy (281) 599-7700 77094 Facility # 7059 Castle Dental - Inner Loop 5712 Kirby Dr (713) 521-3509 77005 Facility # 7052 Castle Dental - Northwest 13486 Northwest Fwy (713) 460-4777 77040 Facility # 4228 Monarch Dental - Gulf Gate 6888 Gulf Frwy # 610 (713) 643-0040 77087 Facility # 36622 Castle Dental - Compaq 21519 Tomball Pkwy # H (281) 376-4848 77070 Facility # 7048 Castle Dental - East 13247 East Fwy (713) 451-8888 77015 Facility # 7049 Monarch Dental - Post Oak 12520 Westheimer Rd (281) 679-8888 77077 Facility # 4229 Monarch Dental - Clear Lake 2321 Bay Area Blvd (281) 480-9870 77058 Facility # 7038 Castle Dental - Champions 5020 FM 1960 Rd W (281) 580-9058 77069 Facility # 7562 Monarch Dental - Fannin 8455 Fannin St # A (713) 797-9041 77054 Facility # 7037 Castle Dental - North 6500 North Fwy # 124 (713) 696-8111 77076 Facility # 7561 Monarch Dental - Main 12341 Main St (713) 729-9898 77035 Facility # 7046 Castle Dental - Southwest 9533 Southwest Frwy (713) 774-7774 77074 Facility # 7593 Monarch Dental - Champions 6510 F M 1960 W (281) 583-0888 77069 Facility # 68809 Castle Dental Eldridge 12246 FM 1960 West (281) 849-1001 77065 Smooke, Dr. Adam Facility # 58511 Adam L Smooke DMD 2450 Fondren Rd # 300 (713) 974-0900 77063 Stone, Dr. James Facility # 68655 GMS Dental - Katy Fwy 11767 Katy Fwy # 505 (281) 679-9340 77079 Stone, Dr. James Facility # 58123 G M S Dental - Main 1445 North Loop W # 1000 (713) 861-3231 77008 *Currently unable to accept new members. Visit our website at www.safeguard.net for the most up-to-date listings. Page: 7