MEDICARE: MARINA 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	1223P0221X	Pediatric Dentistry		TX

General Provider Information

NPI Number	:	1578953766
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARINA DENTAL PLLC

Provider Business Mailing Address
First Line	:	900 S WAYSIDE DR
Second Line	:	SUITE 100
City	:	HOUSTON
State	:	TX
Zip	:	77023-3427
Country	:	US
Telephone Number	:	281-974-3996
Fax Number	:

Provider Business Practice Location Address
First Line	:	5406 AIRLINE DR
Second Line	:	SUITE F
City	:	HOUSTON
State	:	TX
Zip	:	77076-4948
Country	:	US
Telephone Number	:	281-905-6660
Fax Number	:

Authorized Official
Title or Position	:	REGIONAL MANAGER
Name	:	MRS. LAUREN EPP
Credential	:
Telephone Number	:	832-203-7968

Provider Enumeration Date	:	01/27/2015
Last Update Date	:	01/27/2015

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