MEDICARE: BLVD DENTISTRY SPRING 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	122300000X	Dentist

General Provider Information

NPI Number	:	1811496722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLVD DENTISTRY SPRING PLLC

Provider Business Mailing Address
First Line	:	21301 KUYKENDAHL RD STE D
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-2614
Country	:	US
Telephone Number	:	972-869-3789
Fax Number	:

Provider Business Practice Location Address
First Line	:	21301 KUYKENDAHL RD STE D
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77379-2614
Country	:	US
Telephone Number	:	281-407-4561
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING TEAM LEAD
Name	:	PAOLA RAMOS
Credential	:
Telephone Number	:	972-869-3789

Provider Enumeration Date	:	02/06/2018
Last Update Date	:	11/21/2024

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