=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013323435
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY DENTISTRY OF HOUSTON PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2014
-----------------------------------------------------
Last Update Date | 08/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13145 VETERANS MEMORIAL DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77014-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-580-4830
-----------------------------------------------------
Fax | 855-313-5067
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13145 VETERANS MEMORIAL DR
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77014-1903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-580-4830
-----------------------------------------------------
Fax | 855-313-5067
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | CARMEN MARMOL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-580-4830
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25663
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------