Healthcare Provider Details

I. General information

NPI: 1225624505
Provider Name (Legal Business Name): RIVERS EDGE DENTAL, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3403 RIVERS EDGE TRL
KINGWOOD TX
77339-2634
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE STE 190
MARIETTA GA
30067-6405
US

V. Phone/Fax

Practice location:
  • Phone: 281-361-0102
  • Fax:
Mailing address:
  • Phone: 770-916-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DALE MAYFIELD
Title or Position: PRESIDENT
Credential: DMD
Phone: 770-916-5036