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General NPI Number Information
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NPI Number | 1518326750
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Entity Type | Organization
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Legal Business Name | BLOSSOM ORTHODONTICS AND PEDIATRIC DENTISTRY PA
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Dates
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Enumeration Date | 02/16/2016
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Last Update Date | 02/16/2016
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Provider Practice Location Address
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Address Line | 13119 LOUETTA RD
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City | CYPRESS
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State | TX
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Zip | 77429-5155
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Country | US
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Telephone | 281-359-5551
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Fax |
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Provider Business Mailing Address
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Address Line | 134 VINTAGE PARK BLVD SUITE A 109
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City | HOUSTON
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State | TX
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Zip | 77070-3998
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Country | US
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Telephone | 281-359-5551
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | SHUNDA THOMPSON
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Credential | DDS
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Telephone | 281-359-5551
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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