MEDICARE: CARUS 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	1223G0001X	General Practice Dentistry	15769	TX

General Provider Information

NPI Number	:	1740663764
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARUS DENTAL PC

Provider Business Mailing Address
First Line	:	19121 W LAKE HOUSTON PKWY STE E
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-4826
Country	:	US
Telephone Number	:	281-446-2153
Fax Number	:

Provider Business Practice Location Address
First Line	:	19121 W LAKE HOUSTON PKWY STE E
Second Line	:
City	:	HUMBLE
State	:	TX
Zip	:	77346-4826
Country	:	US
Telephone Number	:	281-446-2153
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CELIA HAYES
Credential	:
Telephone Number	:	217-540-2100

Provider Enumeration Date	:	07/08/2015
Last Update Date	:	01/20/2022

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