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General NPI Number Information
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NPI Number | 1760720650
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Entity Type | Organization
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Legal Business Name | FALL CREEK FAMILY DENTAL PLLC
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Dates
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Enumeration Date | 01/28/2013
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Last Update Date | 01/28/2013
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Provider Practice Location Address
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Address Line | 9506 N SAM HOUSTON PKWY E STE 230
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City | HUMBLE
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State | TX
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Zip | 77396-4901
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Country | US
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Telephone | 713-645-1680
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Fax |
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Provider Business Mailing Address
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Address Line | 9506 N SAM HOUSTON PKWY E STE 230
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City | HUMBLE
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State | TX
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Zip | 77396-4901
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | GOHAR BERNAL
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Credential | DMD
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Telephone | 713-645-1680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 25991
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License Number State | TX
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