MEDICARE: IDEAL DENTAL OF CLEARLAKE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1023482999
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL DENTAL OF CLEARLAKE PLLC

Provider Business Mailing Address
First Line	:	3535 CLEAR LAKE CITY BOULEVARD
Second Line	:	SUITE 400
City	:	HOUSTON
State	:	TX
Zip	:	77059
Country	:	US
Telephone Number	:	281-990-0677
Fax Number	:

Provider Business Practice Location Address
First Line	:	3535 CLEAR LAKE CITY BOULEVARD
Second Line	:	SUITE 400
City	:	HOUSTON
State	:	TX
Zip	:	77059
Country	:	US
Telephone Number	:	281-990-0677
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SULMAN AHMED
Credential	:	DMD
Telephone Number	:	281-990-0677

Provider Enumeration Date	:	11/16/2015
Last Update Date	:	08/20/2016

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