=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649669078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIGNATURE SMILES SURGICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2015
-----------------------------------------------------
Last Update Date | 08/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 N SHEPHERD DR STE 3B
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77018-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-802-0011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3800 N SHEPHERD DR SUITE 3B
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77018-6400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-802-0011
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. TERRY LEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 281-224-5331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------