MEDICARE: IDEAL DENTAL OF LEAGUE CITY 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	:	1154875896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL DENTAL OF LEAGUE CITY PLLC

Provider Business Mailing Address
First Line	:	2875 E LEAGUE CITY PKWY
Second Line	:	SUITE 800
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-7158
Country	:	US
Telephone Number	:	832-905-0210
Fax Number	:

Provider Business Practice Location Address
First Line	:	2875 E LEAGUE CITY PKWY
Second Line	:	SUITE 800
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-7158
Country	:	US
Telephone Number	:	832-905-0210
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	SULMAN AHMED
Credential	:	DMD
Telephone Number	:	972-361-0600

Provider Enumeration Date	:	08/11/2016
Last Update Date	:	03/29/2017

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