=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386867752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC DENTAL WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11921 BISSONNET ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77099-1425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-495-3343
-----------------------------------------------------
Fax | 281-495-1125
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11921 BISSONNET ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77099-1425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-495-3343
-----------------------------------------------------
Fax | 281-495-1125
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. PATRICK M RALPH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 281-495-3343
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 20140
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------