MEDICARE: WILLOWBROOK MALL DENTAL

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	1223G0001X	General Practice Dentistry	DN16377	FL

General Provider Information

NPI Number	:	1316287717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOWBROOK MALL DENTAL

Provider Business Mailing Address
First Line	:	1684 WILLOWBROOK MALL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-6027
Country	:	US
Telephone Number	:	917-902-9515
Fax Number	:

Provider Business Practice Location Address
First Line	:	1684 WILLOWBROOK MALL
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77070-6027
Country	:	US
Telephone Number	:	917-902-9515
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. ROSTISLAV KRASNOV
Credential	:	DDS
Telephone Number	:	917-902-9515

Provider Enumeration Date	:	02/21/2013
Last Update Date	:	02/21/2013

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