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General NPI Number Information
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NPI Number | 1548542244
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Entity Type | Organization
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Legal Business Name | MODERN AESTHETICS DENTAL P.A.
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Dates
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Enumeration Date | 09/20/2011
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Last Update Date | 09/20/2011
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Provider Practice Location Address
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Address Line | 25201 KUYKENDAHL RD 450 & 500
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City | TOMBALL
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State | TX
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Zip | 77375-3351
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Country | US
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Telephone | 504-909-9434
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Fax |
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Provider Business Mailing Address
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Address Line | 3410 LOUISIANA ST 3309
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City | HOUSTON
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State | TX
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Zip | 77002-9500
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. MICHAEL P CIMINO
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Credential | DDS
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Telephone | 504-909-9434
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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 | 24594
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License Number State | TX
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