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General NPI Number Information
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NPI Number | 1417491994
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Entity Type | Organization
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Legal Business Name | AUBURN LAKES PERIODONTICS
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Dates
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Enumeration Date | 12/18/2016
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Last Update Date | 12/18/2016
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Provider Practice Location Address
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Address Line | 6922 W RAYFORD RD
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City | SPRING
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State | TX
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Zip | 77389-3003
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Country | US
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Telephone | 832-953-3100
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Fax | 832-953-3101
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Provider Business Mailing Address
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Address Line | 6922 W RAYFORD RD
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City | SPRING
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State | TX
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Zip | 77389-3003
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Country | US
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Telephone | 832-953-3100
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Fax | 832-953-3101
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Authorized Official
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Title or Position | PRESIDENT
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Name | THALIDA THUY DONG
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Credential | DMD, MS
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Telephone | 832-953-3100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 25863
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License Number State | TX
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