=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689191454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | R. TERRY COUNCILL, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2017
-----------------------------------------------------
Last Update Date | 08/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12835 LOUETTA RD
-----------------------------------------------------
City | CYPRESS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77429-5207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-376-9246
-----------------------------------------------------
Fax | 281-370-8398
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10924 GRANT RD STE 310
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-4445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-376-9246
-----------------------------------------------------
Fax | 281-370-8398
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | SUSAN DESPORTE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-376-9246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 28492
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 13448
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------