MEDICARE: IAN ANTHONY SPORT DDS

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	31190	TX

General Provider Information

NPI Number	:	1689058307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IAN ANTHONY SPORT DDS

Provider Business Mailing Address
First Line	:	155 BIRDSALL ST
Second Line	:	#406
City	:	HOUSTON
State	:	TX
Zip	:	77007-2569
Country	:	US
Telephone Number	:	817-217-5110
Fax Number	:

Provider Business Practice Location Address
First Line	:	6421 W 43RD ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77092-4005
Country	:	US
Telephone Number	:	817-217-5110
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2015
Last Update Date	:	07/13/2015

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Directions to “ IAN ANTHONY SPORT DDS” Practice Location

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