MEDICARE: DENTAL LAND 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

General Provider Information

NPI Number	:	1578197208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL LAND PLLC

Provider Business Mailing Address
First Line	:	2525 SOUTHMORE AVE # SITE200
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77502-1451
Country	:	US
Telephone Number	:	713-434-6170
Fax Number	:	713-434-6189

Provider Business Practice Location Address
First Line	:	2525 SOUTHMORE AVE # SITE200
Second Line	:
City	:	PASADENA
State	:	TX
Zip	:	77502-1451
Country	:	US
Telephone Number	:	713-434-6170
Fax Number	:	713-434-6189

Authorized Official
Title or Position	:	MANAGER
Name	:	SIROUS RASTI
Credential	:
Telephone Number	:	713-434-6170

Provider Enumeration Date	:	03/03/2020
Last Update Date	:	03/03/2020

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Directions to “DENTAL LAND PLLC ” Practice Location

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