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General NPI Number Information
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NPI Number | 1689098303
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Entity Type | Organization
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Legal Business Name | CONROE FAMILY DENTISTRY PLLC
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Dates
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Enumeration Date | 02/17/2014
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Last Update Date | 10/27/2021
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Provider Practice Location Address
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Address Line | 1362 WILSON RD
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City | CONROE
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State | TX
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Zip | 77304-2146
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Country | US
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Telephone | 936-539-2211
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Fax | 936-539-2216
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Provider Business Mailing Address
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Address Line | 1362 WILSON RD
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City | CONROE
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State | TX
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Zip | 77304-2146
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Country | US
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Telephone | 936-539-2211
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Fax | 936-539-2216
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Authorized Official
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Title or Position | MEMBER
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Name | LOGAN WOOD
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Credential | DDS
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Telephone | 936-539-2211
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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 | 23937
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License Number State | TX
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