Healthcare Provider Details

I. General information

NPI: 1285106716
Provider Name (Legal Business Name): DENTASPA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 10/28/2022
Certification Date: 10/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 INTERSTATE 45 N STE 300
CONROE TX
77303-7912
US

IV. Provider business mailing address

2960 INTERSTATE 45 N STE 300
CONROE TX
77303-7912
US

V. Phone/Fax

Practice location:
  • Phone: 909-471-3670
  • Fax: 210-447-7088
Mailing address:
  • Phone: 909-471-3670
  • Fax: 210-447-7088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. HAITHAM AL-SALMAN
Title or Position: OWNER
Credential: DDS
Phone: 909-471-3670