MEDICARE: DICKENS AND ASSOCIATES P.C. DBA FULTON DENTAL ASSOCIATES

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	19874	TX

General Provider Information

NPI Number	:	1720256084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DICKENS AND ASSOCIATES P.C. DBA FULTON DENTAL ASSOCIATES

Provider Business Mailing Address
First Line	:	2445 FULTON ST
Second Line	:	SUITE, B
City	:	HOUSTON
State	:	TX
Zip	:	77009-7837
Country	:	US
Telephone Number	:	713-225-2266
Fax Number	:	713-225-2275

Provider Business Practice Location Address
First Line	:	2445 FULTON ST
Second Line	:	SUITE, B
City	:	HOUSTON
State	:	TX
Zip	:	77009-7837
Country	:	US
Telephone Number	:	713-225-2266
Fax Number	:	713-225-2275

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	SHANNON PRESLEY DICKENS
Credential	:	D.D.S.
Telephone Number	:	713-225-2266

Provider Enumeration Date	:	02/20/2008
Last Update Date	:	02/20/2008

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