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General NPI Number Information
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NPI Number | 1700260718
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Entity Type | Organization
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Legal Business Name | WE CREATE YOUR PERFECT SMILE PC
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Dates
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Enumeration Date | 07/20/2015
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Last Update Date | 07/20/2015
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Provider Practice Location Address
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Address Line | 1939 LAWRENCE RD
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City | KEMAH
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State | TX
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Zip | 77565-3122
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Country | US
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Telephone | 281-538-9300
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Fax | 281-538-9031
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Provider Business Mailing Address
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Address Line | 1939 LAWRENCE RD
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City | KEMAH
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State | TX
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Zip | 77565-3122
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Country | US
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Telephone | 281-538-9300
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Fax | 281-538-9031
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Authorized Official
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Title or Position | PARTNER
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Name | TRACIE L DEVAULT
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Credential | DDS
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Telephone | 281-538-9300
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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 | 22158
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License Number State | TX
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