Healthcare Provider Details

I. General information

NPI: 1386867752
Provider Name (Legal Business Name): PEDIATRIC DENTAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11921 BISSONNET ST
HOUSTON TX
77099-1425
US

IV. Provider business mailing address

11921 BISSONNET ST
HOUSTON TX
77099-1425
US

V. Phone/Fax

Practice location:
  • Phone: 281-495-3343
  • Fax: 281-495-1125
Mailing address:
  • Phone: 281-495-3343
  • Fax: 281-495-1125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number20140
License Number StateTX

VIII. Authorized Official

Name: DR. PATRICK M RALPH
Title or Position: PRESIDENT
Credential: DMD
Phone: 281-495-3343