MEDICARE: RADIANT ORTHODONTICS, 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	22757	TX
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	22757	TX

General Provider Information

NPI Number	:	1962721878
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RADIANT ORTHODONTICS, PLLC

Provider Business Mailing Address
First Line	:	9009 LONG POINT RD
Second Line	:	SUITE A1
City	:	HOUSTON
State	:	TX
Zip	:	77055-4665
Country	:	US
Telephone Number	:	713-468-9009
Fax Number	:	713-463-6403

Provider Business Practice Location Address
First Line	:	9009 LONG POINT RD
Second Line	:	SUITE A1
City	:	HOUSTON
State	:	TX
Zip	:	77055-4665
Country	:	US
Telephone Number	:	713-468-9009
Fax Number	:	713-463-6403

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ELAHEH MOHEB
Credential	:	DDS
Telephone Number	:	713-922-8838

Provider Enumeration Date	:	05/18/2010
Last Update Date	:	09/19/2012

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