=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073964888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HILLCROFT DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2016
-----------------------------------------------------
Last Update Date | 06/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3838 HILLCROFT ST STE 325
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77057-7736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-266-0366
-----------------------------------------------------
Fax | 713-780-2222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3838 HILLCROFT ST STE 325
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77057-7736
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-266-0366
-----------------------------------------------------
Fax | 713-780-2222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JIMMY TRAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 713-266-0366
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------