=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356569065
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FARIDE CERTUCHE DDS.,P.A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2007
-----------------------------------------------------
Last Update Date | 07/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4142 BELLAIRE BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-661-4234
-----------------------------------------------------
Fax | 713-661-7625
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4142 BELLAIRE BLVD
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77025-1008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-661-4234
-----------------------------------------------------
Fax | 713-661-7625
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. FARIDE CERTUCHE
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 713-661-4234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------