MEDICARE: REJI MAMMEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	34406	TX

General Provider Information

NPI Number	:	1104304542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REJI MAMMEN

Provider Business Mailing Address
First Line	:	2120 EL PASEO ST APT 2607
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054-3232
Country	:	US
Telephone Number	:	832-270-6851
Fax Number	:

Provider Business Practice Location Address
First Line	:	2120 EL PASEO ST., APT 2607
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77054
Country	:	US
Telephone Number	:	832-270-6851
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/28/2018
Last Update Date	:	07/28/2018

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Directions to “ REJI MAMMEN ” Practice Location

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