MEDICARE: MODERN AESTHETICS DENTAL P.A.

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	24594	TX

General Provider Information

NPI Number	:	1548542244
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MODERN AESTHETICS DENTAL P.A.

Provider Business Mailing Address
First Line	:	3410 LOUISIANA ST
Second Line	:	3309
City	:	HOUSTON
State	:	TX
Zip	:	77002-9500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	25201 KUYKENDAHL RD
Second Line	:	450 & 500
City	:	TOMBALL
State	:	TX
Zip	:	77375-3351
Country	:	US
Telephone Number	:	504-909-9434
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. MICHAEL P CIMINO
Credential	:	DDS
Telephone Number	:	504-909-9434

Provider Enumeration Date	:	09/20/2011
Last Update Date	:	09/20/2011

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