MEDICARE: PEDIATRIC DENTAL WELLNESS

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	20140	TX

General Provider Information

NPI Number	:	1386867752
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEDIATRIC DENTAL WELLNESS

Provider Business Mailing Address
First Line	:	11921 BISSONNET ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77099-1425
Country	:	US
Telephone Number	:	281-495-3343
Fax Number	:	281-495-1125

Provider Business Practice Location Address
First Line	:	11921 BISSONNET ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77099-1425
Country	:	US
Telephone Number	:	281-495-3343
Fax Number	:	281-495-1125

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. PATRICK M RALPH
Credential	:	DMD
Telephone Number	:	281-495-3343

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/22/2020

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