=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689166415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATION ENDODONTICS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2018
-----------------------------------------------------
Last Update Date | 06/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7830 W GRAND PKWY S STE 295
-----------------------------------------------------
City | RICHMOND
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77406-5816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-961-0961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3255 LAS PALMAS ST APT 545
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77027-5779
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-805-7080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MINA RIZK
-----------------------------------------------------
Credential | BDS, MSD
-----------------------------------------------------
Telephone | 713-805-7080
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 32411
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------