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General NPI Number Information
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NPI Number | 1013458983
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Entity Type | Organization
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Legal Business Name | FWB DENTAL, P.L.L.C.
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Dates
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Enumeration Date | 03/13/2017
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Last Update Date | 03/13/2017
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Provider Practice Location Address
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Address Line | 1012 BAYBROOK MALL
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City | FRIENDSWOOD
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State | TX
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Zip | 77546-2744
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Country | US
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Telephone | 281-461-6515
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Fax | 281-461-6687
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Provider Business Mailing Address
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Address Line | 1012 BAYBROOK MALL
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City | FRIENDSWOOD
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State | TX
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Zip | 77546-2744
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Country | US
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Telephone | 281-461-6515
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Fax | 281-461-6687
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. VLADA MATYTSIN
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Credential | D.D.S.
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Telephone | 281-461-6515
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 30466
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License Number State | TX
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