Healthcare Provider Details

I. General information

NPI: 1346430568
Provider Name (Legal Business Name): MAISA M IDRISS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16215 NORTH FREEWAY STE 100
HOUSTON TX
77090
US

IV. Provider business mailing address

16215 NORTH FREEWAY STE 100
HOUSTON TX
77090
US

V. Phone/Fax

Practice location:
  • Phone: 281-444-0030
  • Fax: 281-440-5192
Mailing address:
  • Phone: 281-444-0030
  • Fax: 281-440-5192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number17900
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: