MEDICARE: MAPLE LEAF DENTAL, PC

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	1223P0700X	Prosthodontics

General Provider Information

NPI Number	:	1649142233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAPLE LEAF DENTAL, PC

Provider Business Mailing Address
First Line	:	14754 MEMORIAL DR STE 100
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-5275
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	14754 MEMORIAL DR STE 100
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-5275
Country	:	US
Telephone Number	:	281-497-5558
Fax Number	:	281-497-7181

Authorized Official
Title or Position	:	DDS
Name	:	LISA GIOVANETTI
Credential	:
Telephone Number	:	281-497-5558

Provider Enumeration Date	:	09/22/2025
Last Update Date	:	09/22/2025

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