=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184027773
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RADHIKA GOWALI D.D.S
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2014
-----------------------------------------------------
Last Update Date | 10/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21211 FM 529 RD STE 106
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77433-6802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-520-3445
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2208 CONVERSE ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77006-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-303-8825
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30617
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------