=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073872636
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KUSUMKUMAR DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2012
-----------------------------------------------------
Last Update Date | 05/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1022 PASADENA BLVD BLDG SUITEC
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77506-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-473-4358
-----------------------------------------------------
Fax | 713-473-4358
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1022 PASADENA BLVD BLDG SUITEC
-----------------------------------------------------
City | PASADENA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77506-4750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-473-4358
-----------------------------------------------------
Fax | 713-473-4358
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | KUSUM KAPOOR KUMAR
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 713-473-4358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 15177
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------