MEDICARE: DR. MARY ANN GRACE SAGULLO DDS

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	20093	TX

General Provider Information

NPI Number	:	1114143104
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ANN GRACE SAGULLO DDS

Provider Business Mailing Address
First Line	:	22235 RUSSELL DRIVE
Second Line	:
City	:	NEW CANEY
State	:	TX
Zip	:	77357
Country	:	US
Telephone Number	:	281-689-1760
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 N LOOP WEST
Second Line	:	SUITE 1000
City	:	HOUSTON
State	:	TX
Zip	:	77008
Country	:	US
Telephone Number	:	713-861-3231
Fax Number	:	713-426-1720

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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