MEDICARE: HOLLYWOOD DENTIST FOUR

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	30127	TX

General Provider Information

NPI Number	:	1619367612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLLYWOOD DENTIST FOUR

Provider Business Mailing Address
First Line	:	12620 WOODFOREST BLVD STE 420A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77015-3643
Country	:	US
Telephone Number	:	713-637-8000
Fax Number	:	713-637-6558

Provider Business Practice Location Address
First Line	:	12620 WOODFOREST BLVD STE 420A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77015-3643
Country	:	US
Telephone Number	:	713-637-8000
Fax Number	:	713-637-6558

Authorized Official
Title or Position	:	OWNER
Name	:	JEFFREY M. TANG
Credential	:	D.D.S
Telephone Number	:	713-637-8000

Provider Enumeration Date	:	01/28/2015
Last Update Date	:	01/28/2015

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Directions to “HOLLYWOOD DENTIST FOUR ” Practice Location

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