MEDICARE: FIESTA SMILES 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	1223G0001X	General Practice Dentistry	24365	TX

General Provider Information

NPI Number	:	1457711764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIESTA SMILES PLLC

Provider Business Mailing Address
First Line	:	1301 FM 2218
Second Line	:	500-B
City	:	RICHMOND
State	:	TX
Zip	:	77469
Country	:	US
Telephone Number	:	682-234-4603
Fax Number	:

Provider Business Practice Location Address
First Line	:	1301 FM 2218
Second Line	:	500-B
City	:	RICHMOND
State	:	TX
Zip	:	77469
Country	:	US
Telephone Number	:	682-234-4603
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	GAURAV PURI
Credential	:
Telephone Number	:	682-234-4603

Provider Enumeration Date	:	02/29/2016
Last Update Date	:	02/29/2016

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