=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083223960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AVILAB DENTAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2020
-----------------------------------------------------
Last Update Date | 07/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5115 BUFFALO SPEEDWAY STE 700
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005-4213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-381-0861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6407 GREENCREEK MEADOWS LN
-----------------------------------------------------
City | SPRING
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77379-8243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-381-0861
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. KRISTIN TOMEI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-381-0861
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 292200000X
-----------------------------------------------------
Taxonomy Name | Dental Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------