Healthcare Provider Details

I. General information

NPI: 1255568648
Provider Name (Legal Business Name): TATYANA VAZEMILLER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2009
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4429 GRIGGS RD STE A
HOUSTON TX
77021-2852
US

IV. Provider business mailing address

16535 TOWN LAKE CT
HOUSTON TX
77059-5546
US

V. Phone/Fax

Practice location:
  • Phone: 281-979-7688
  • Fax:
Mailing address:
  • Phone: 281-979-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number28354
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: