MEDICARE: FAV-ULOUS DENTAL 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	122300000X	Dentist
2	1223E0200X	Endodontics
3	1223G0001X	General Practice Dentistry
4	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
5	124Q00000X	Dental Hygienist
6	126800000X	Dental Assistant
7	122300000X	Dentist	30122	TX

General Provider Information

NPI Number	:	1578008736
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAV-ULOUS DENTAL PLLC

Provider Business Mailing Address
First Line	:	8762 LONG POINT RD
Second Line	:	102
City	:	HOUSTON
State	:	TX
Zip	:	77055-3030
Country	:	US
Telephone Number	:	713-468-1400
Fax Number	:	713-468-8146

Provider Business Practice Location Address
First Line	:	8762 LONG POINT RD
Second Line	:	102
City	:	HOUSTON
State	:	TX
Zip	:	77055-3030
Country	:	US
Telephone Number	:	713-468-1400
Fax Number	:	713-468-8146

Authorized Official
Title or Position	:	DENTIST
Name	:	MRS. FABIOLA GARCIA DE ROCHA
Credential	:	DDS
Telephone Number	:	713-468-1400

Provider Enumeration Date	:	12/27/2016
Last Update Date	:	12/27/2016

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