Healthcare Provider Details

I. General information

NPI: 1730550161
Provider Name (Legal Business Name): TLN FAMILY & COSMETIC DENTAL @ PEARLAND PARKWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2015
Last Update Date: 10/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 PEARLAND PARKWAY SUITE 201
PEARLAND TX
77581
US

IV. Provider business mailing address

63 GENOVA WAY LANE
MISSOURI CITY TX
77459
US

V. Phone/Fax

Practice location:
  • Phone: 713-723-2600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number22283
License Number StateTX

VIII. Authorized Official

Name: DR. TAMMEKA NICKLEBERRY
Title or Position: CEO
Credential: DDS
Phone: 713-723-2600