MEDICARE: DENTAL AESTHETICS OF TEXAS

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1265790539
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL AESTHETICS OF TEXAS

Provider Business Mailing Address
First Line	:	PO BOX 300448
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77230-0448
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6120 SCOTT ST STE B
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77021-2698
Country	:	US
Telephone Number	:	713-444-7768
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DEREK TILLMAN
Credential	:	D.M.D.
Telephone Number	:	713-444-7768

Provider Enumeration Date	:	04/24/2012
Last Update Date	:	12/01/2012

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Directions to “DENTAL AESTHETICS OF TEXAS ” Practice Location

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