Healthcare Provider Details

I. General information

NPI: 1417198615
Provider Name (Legal Business Name): TLN FAMILY DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2009
Last Update Date: 03/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14522 S POST OAK RD SUITE 110A
HOUSTON TX
77045-6037
US

IV. Provider business mailing address

5734 GASSER LN
HOUSTON TX
77085-5200
US

V. Phone/Fax

Practice location:
  • Phone: 713-723-2600
  • Fax:
Mailing address:
  • Phone: 832-654-2143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22283
License Number StateTX

VIII. Authorized Official

Name: DR. TAMMEKA LA KEISHA NICKLEBERRY
Title or Position: OWNER
Credential: D.D.S.
Phone: 832-654-2143