Healthcare Provider Details

I. General information

NPI: 1750165767
Provider Name (Legal Business Name): LONESTAR GRINS DENTAL AND ORTHODONTICS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3648 FM 1960 RD W STE 246B
HOUSTON TX
77068-3617
US

IV. Provider business mailing address

12022 VIA PALAZZO LN
CYPRESS TX
77429-7434
US

V. Phone/Fax

Practice location:
  • Phone: 281-919-2983
  • Fax:
Mailing address:
  • Phone: 171-377-5288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: SHUNDA THOMPSON BANKS
Title or Position: OWNER
Credential: DDS
Phone: 713-775-2888