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General NPI Number Information
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NPI Number | 1366982324
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Entity Type | Organization
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Legal Business Name | FWB DENTAL P.L.L.C.
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Dates
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Enumeration Date | 02/24/2017
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Last Update Date | 10/24/2018
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Provider Practice Location Address
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Address Line | 4840 SWEETWATER BLVD STE A
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City | SUGAR LAND
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State | TX
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Zip | 77479-3403
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Country | US
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Telephone | 832-939-9999
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Fax | 832-939-9997
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Provider Business Mailing Address
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Address Line | 4840 SWEETWATER BLVD STE A
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City | SUGAR LAND
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State | TX
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Zip | 77479-3403
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Country | US
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Telephone | 832-939-9999
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Fax | 832-939-9997
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. VLADA MATYTSIN
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Credential | DDS
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Telephone | 832-939-9999
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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 | 30466
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License Number State | TX
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