=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417770322
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARM DENTAL CYPRESS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2024
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28427 TX-249
-----------------------------------------------------
City | TOMBALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-214-5137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5310 FAIRDALE LN
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77056-6605
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-214-5137
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. RADHIKA SHAH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-214-5137
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------