MEDICARE: CONROE FAMILY DENTISTRY 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	23937	TX

General Provider Information

NPI Number	:	1689098303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONROE FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	1362 WILSON RD
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-2146
Country	:	US
Telephone Number	:	936-539-2211
Fax Number	:	936-539-2216

Provider Business Practice Location Address
First Line	:	1362 WILSON RD
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77304-2146
Country	:	US
Telephone Number	:	936-539-2211
Fax Number	:	936-539-2216

Authorized Official
Title or Position	:	MEMBER
Name	:	LOGAN WOOD
Credential	:	DDS
Telephone Number	:	936-539-2211

Provider Enumeration Date	:	02/17/2014
Last Update Date	:	10/27/2021

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