MEDICARE: FIESTA DENTISTRY, P.A.

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033328174
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIESTA DENTISTRY, P.A.

Provider Business Mailing Address
First Line	:	723A SHOTWELL ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77020-4813
Country	:	US
Telephone Number	:	713-670-8922
Fax Number	:	713-670-7969

Provider Business Practice Location Address
First Line	:	723A SHOTWELL ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77020-4813
Country	:	US
Telephone Number	:	713-670-8922
Fax Number	:	713-670-7969

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. HIEP NGUYEN
Credential	:	D.D.S.
Telephone Number	:	713-670-8922

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	10/01/2008

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