=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760288781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IMMA DENTAL INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2025
-----------------------------------------------------
Last Update Date | 03/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13843 HIGHWAY 105 W STE 106
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77304-5704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-324-1094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 469 FM 1488 RD STE 103
-----------------------------------------------------
City | CONROE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77384-4189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-299-0884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | FRI VEKUH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 936-324-1094
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------