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General NPI Number Information
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NPI Number | 1780962456
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Entity Type | Organization
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Legal Business Name | TOMBALL FAMILY DENTAL
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Dates
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Enumeration Date | 07/29/2011
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Last Update Date | 10/17/2011
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Provider Practice Location Address
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Address Line | 14060 FM 2920 RD SUITE H
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City | TOMBALL
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State | TX
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Zip | 77377-5502
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Country | US
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Telephone | 281-389-2720
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Fax |
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Provider Business Mailing Address
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Address Line | 14090 FM 2920 RD SUITE H
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City | TOMBALL
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State | TX
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Zip | 77377-5549
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Country | US
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Telephone | 281-516-1222
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Fax |
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Authorized Official
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Title or Position | P.C.
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Name | DR. AUDRA LEANN HIEMSTRA
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Credential | D.D.S.
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Telephone | 281-389-2720
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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 | 24722
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License Number State | TX
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