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General NPI Number Information
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NPI Number | 1619354693
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Entity Type | Organization
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Legal Business Name | MONTGOMERY COMPREHENSIVE DENTAL CENTER
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Dates
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Enumeration Date | 04/29/2015
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Last Update Date | 04/29/2015
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Provider Practice Location Address
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Address Line | 2210 N FRAZIER ST SUITE #120
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City | CONROE
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State | TX
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Zip | 77303-1780
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Country | US
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Telephone | 936-539-3636
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Fax | 936-539-3639
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Provider Business Mailing Address
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Address Line | 0951 LONESTAR PARKWAY
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City | MONTGOMERY
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State | TX
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Zip | 77356-0951
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Country | US
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Telephone | 936-230-5445
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Fax |
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Authorized Official
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Title or Position | FINANCIAL COORDINATOR
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Name | MISS RACHEL D STARK
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Credential |
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Telephone | 936-539-3636
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 16499
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License Number State | TX
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