MEDICARE: EMERALD VENTURE

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	:	1699065037
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMERALD VENTURE

Provider Business Mailing Address
First Line	:	PO BOX 293
Second Line	:
City	:	BARKER
State	:	TX
Zip	:	77413-0293
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11602 VETERANS MEMORIAL DR
Second Line	:	SUITE E
City	:	HOUSTON
State	:	TX
Zip	:	77067-2606
Country	:	US
Telephone Number	:	713-382-9893
Fax Number	:	713-382-9893

Authorized Official
Title or Position	:	SECRETARY
Name	:	A PHAM
Credential	:
Telephone Number	:	713-382-9893

Provider Enumeration Date	:	04/19/2011
Last Update Date	:	04/19/2011

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Directions to “EMERALD VENTURE ” Practice Location

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