Healthcare Provider Details

I. General information

NPI: 1467722215
Provider Name (Legal Business Name): COPPERFIELD SMILE CENTER, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2012
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15218 WEST RD
HOUSTON TX
77095-1916
US

IV. Provider business mailing address

2535 FM 1960 EAST
HOUSTON TX
77073
US

V. Phone/Fax

Practice location:
  • Phone: 281-550-7276
  • Fax: 281-550-7295
Mailing address:
  • Phone: 281-550-7276
  • Fax: 281-550-7295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON MICHAEL DERR
Title or Position: PARTNER
Credential: DDS
Phone: 281-443-7524