Healthcare Provider Details

I. General information

NPI: 1154738151
Provider Name (Legal Business Name): FIRST COLONY MALL DENTAL PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16535 SOUTHWEST FWY 570
SUGAR LAND TX
77479-2321
US

IV. Provider business mailing address

16535 SOUTHWEST FWY 570
SUGAR LAND TX
77479-2321
US

V. Phone/Fax

Practice location:
  • Phone: 954-846-7171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27827
License Number StateTX

VIII. Authorized Official

Name: ROSTISLAV KRASNOV
Title or Position: OWNER
Credential: DDS
Phone: 954-846-7171