MEDICARE: CAPSTONE DENTISTRY PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223P0221X	Pediatric Dentistry
2	1223P0300X	Periodontics
3	1223P0700X	Prosthodontics
4	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
5	122300000X	Dentist

General Provider Information

NPI Number	:	1619459161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPSTONE DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	9526 N SAM HOUSTON PKWY E
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77396-4733
Country	:	US
Telephone Number	:	832-361-3222
Fax Number	:	832-361-3212

Provider Business Practice Location Address
First Line	:	9526 N SAM HOUSTON PKWY E
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77396-4733
Country	:	US
Telephone Number	:	832-361-3222
Fax Number	:	832-361-3212

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JESSICA JACKSON
Credential	:
Telephone Number	:	832-361-3222

Provider Enumeration Date	:	08/31/2018
Last Update Date	:	08/31/2018

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