MEDICARE: PREMIER DENTAL CLUB PC

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	:	1851025118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER DENTAL CLUB PC

Provider Business Mailing Address
First Line	:	9720 CYPRESSWOOD DR STE 200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-3357
Country	:	US
Telephone Number	:	346-296-9056
Fax Number	:	346-501-4160

Provider Business Practice Location Address
First Line	:	9720 CYPRESSWOOD DR STE 200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-3357
Country	:	US
Telephone Number	:	346-296-9056
Fax Number	:	346-501-4160

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JAYA MANGAL
Credential	:	DDS
Telephone Number	:	848-218-8836

Provider Enumeration Date	:	07/13/2022
Last Update Date	:	08/28/2025

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