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General NPI Number Information
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NPI Number | 1194425942
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Entity Type | Individual
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Provider Name | NIMMY SHAJAN PAUL
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Gender | Female
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Dates
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Enumeration Date | 03/08/2023
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Last Update Date | 09/04/2024
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Provider Practice Location Address
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Address Line | 301 CONSTITUTION DR
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City | COPPERAS COVE
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State | TX
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Zip | 76522-2653
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Country | US
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Telephone | 254-978-5938
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Fax |
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Provider Business Mailing Address
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Address Line | 1202 S FM 116 APT 10202
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City | COPPERAS COVE
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State | TX
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Zip | 76522-3653
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Country | US
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Telephone | 443-535-7824
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 40836
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License Number State | TX
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