MEDICARE: FANTASTIC SMILES OF HOUSTON PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1164390464
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FANTASTIC SMILES OF HOUSTON PLLC

Provider Business Mailing Address
First Line	:	2617 W HOLCOMBE BLVD STE 1
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-1757
Country	:	US
Telephone Number	:	832-862-1111
Fax Number	:	832-487-9247

Provider Business Practice Location Address
First Line	:	2617 W HOLCOMBE BLVD STE 1
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77025-1757
Country	:	US
Telephone Number	:	832-862-1111
Fax Number	:	832-487-9247

Authorized Official
Title or Position	:	PAYER ENROLLMENT MANAGER
Name	:	JENNY GARCIA
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	10/28/2025
Last Update Date	:	10/28/2025

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