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General NPI Number Information
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NPI Number | 1659507002
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Entity Type | Organization
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Legal Business Name | PERIOGOLDENTAL P.A
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Dates
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Enumeration Date | 05/29/2009
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Last Update Date | 05/29/2009
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Provider Practice Location Address
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Address Line | 115 N DIXIE DR STE 300
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5958
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Country | US
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Telephone | 979-285-9998
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Fax | 979-480-0411
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Provider Business Mailing Address
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Address Line | 115 N DIXIE DR STE 300
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5958
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Country | US
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Telephone | 979-285-9998
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Fax | 979-480-0411
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CRISTINA ROSS
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Credential | DDS
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Telephone | 979-285-9998
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 20347
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License Number State | TX
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