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NPI Code Detail

MEDICARE: SMILE RESTORATIONS, PA

MEDICARE: SMILE RESTORATIONS, PA
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
1122300000XDentist

General Provider Information

NPI Number : 1568729093
Entity Type Code : Organization
Provider Name (Legal Business Name) : SMILE RESTORATIONS, PA
Provider Business Mailing Address
First Line : PO BOX 300448
Second Line :
City : HOUSTON
State : TX
Zip : 77230-0448
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 2276 HOLCOMBE BLVD
Second Line :
City : HOUSTON
State : TX
Zip : 77030-4224
Country : US
Telephone Number : 713-793-5555
Fax Number :
Authorized Official
Title or Position : PRESIDENT
Name : DR. DEREK TILLMAN
Credential : DMD
Telephone Number : 713-793-5555
Provider Enumeration Date : 04/23/2012
Last Update Date : 05/02/2016

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Directions to “SMILE RESTORATIONS, PA ” Practice Location

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