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NPI Code Detail

MEDICARE: MODERN AESTHETICS DENTAL P.A.

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
11223G0001XGeneral Practice Dentistry24594TX

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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