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General NPI Number Information
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NPI Number | 1174787378
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Entity Type | Organization
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Legal Business Name | CENTRA TWO DENTAL
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Dates
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Enumeration Date | 07/16/2008
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Last Update Date | 07/16/2008
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Provider Practice Location Address
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Address Line | 5103 BROADWAY ST 109
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City | PEARLAND
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State | TX
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Zip | 77581-3900
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Country | US
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Telephone | 281-485-7767
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Fax | 281-485-7745
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Provider Business Mailing Address
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Address Line | 5103 BROADWAY ST 109
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City | PEARLAND
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State | TX
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Zip | 77581-3900
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Country | US
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Telephone | 281-485-7767
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Fax | 281-485-7745
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Authorized Official
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Title or Position | OWNER
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Name | HIEP DUY PHAM
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Credential | DDS
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Telephone | 281-485-7767
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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 | 19860
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License Number State | TX
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