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General NPI Number Information
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NPI Number | 1487811659
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Entity Type | Organization
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Legal Business Name | SPACE CITY PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 05/16/2008
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Last Update Date | 10/30/2023
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Provider Practice Location Address
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Address Line | 18174 GULF FWY STE 100
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City | FRIENDSWOOD
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State | TX
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Zip | 77546-2722
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Country | US
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Telephone | 281-484-7732
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Fax | 888-397-0197
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Provider Business Mailing Address
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Address Line | 18174 GULF FWY STE 100
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City | FRIENDSWOOD
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State | TX
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Zip | 77546-2722
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Country | US
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Telephone | 281-484-7732
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Fax | 281-484-8751
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Authorized Official
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Title or Position | OWNER
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Name | BRET A IBARRA
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Credential | DDS, MSD
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Telephone | 281-484-7732
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 10310
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License Number State | TX
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