Healthcare Provider Details

I. General information

NPI: 1912563958
Provider Name (Legal Business Name): CISNEROS DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 05/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

918 W SOUTHMORE AVE STE 115
PASADENA TX
77502-1020
US

IV. Provider business mailing address

918 W SOUTHMORE AVE STE 115
PASADENA TX
77502-1020
US

V. Phone/Fax

Practice location:
  • Phone: 832-489-2881
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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: CARMEN MARMOL
Title or Position: OFFICE MANAGER
Credential:
Phone: 832-489-2881