=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689002164
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CYPRESS CREEK DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2013
-----------------------------------------------------
Last Update Date | 10/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27118 WINDY GROVE LN
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77433-7570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-639-4831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27118 WINDY GROVE LN
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77433-7570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-639-4831
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. SHABBIR YAHYA BOXWALLA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 281-639-4831
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 20264
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------