MEDICARE: NORTHWEST PEDIATRIC 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	1223P0221X	Pediatric Dentistry	20388	TX

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346409489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST PEDIATRIC DENTAL

Provider Business Mailing Address
First Line	:	17222 RED OAK DR
Second Line	:	SUITE 104
City	:	HOUSTON
State	:	TX
Zip	:	77090-2648
Country	:	US
Telephone Number	:	281-583-4600
Fax Number	:	281-586-7051

Provider Business Practice Location Address
First Line	:	17222 RED OAK DR
Second Line	:	SUITE 104
City	:	HOUSTON
State	:	TX
Zip	:	77090-2648
Country	:	US
Telephone Number	:	281-583-4600
Fax Number	:	281-586-7051

Authorized Official
Title or Position	:	OWNER
Name	:	DR. MARIA A GREEN
Credential	:	D.D.S
Telephone Number	:	281-583-4600

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	06/04/2008

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Directions to “NORTHWEST PEDIATRIC DENTAL ” Practice Location

Language	Start Address	Practice Location

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