MEDICARE: TAB R IMDACHA 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	31602	TX

General Provider Information

NPI Number	:	1710342902
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAB R IMDACHA DDS

Provider Business Mailing Address
First Line	:	1885 EL PASEO ST
Second Line	:	APT 813
City	:	HOUSTON
State	:	TX
Zip	:	77054-3089
Country	:	US
Telephone Number	:	512-350-0760
Fax Number	:

Provider Business Practice Location Address
First Line	:	1885 EL PASEO ST
Second Line	:	APT 813
City	:	HOUSTON
State	:	TX
Zip	:	77054-3089
Country	:	US
Telephone Number	:	512-350-0760
Fax Number	:

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

Provider Enumeration Date	:	12/15/2015
Last Update Date	:	12/15/2015

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Directions to “ TAB R IMDACHA DDS” Practice Location

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