Healthcare Provider Details

I. General information

NPI: 1386654358
Provider Name (Legal Business Name): MARTIN CARLOS CUELLAR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13231 CHAMPION FOREST DR SUITE 304
HOUSTON TX
77069-2600
US

IV. Provider business mailing address

13231 CHAMPION FOREST DR SUITE 304
HOUSTON TX
77069-2600
US

V. Phone/Fax

Practice location:
  • Phone: 281-444-2755
  • Fax:
Mailing address:
  • Phone: 281-444-2755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9300
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: