MEDICARE: IDEAL DENTAL

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	30113	TX

General Provider Information

NPI Number	:	1760866800
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDEAL DENTAL

Provider Business Mailing Address
First Line	:	216 WEST LITTLE YORK
Second Line	:	STE B
City	:	HOUSTON
State	:	TX
Zip	:	77076
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	216 W LITTLE YORK RD
Second Line	:	STE B
City	:	HOUSTON
State	:	TX
Zip	:	77076-1432
Country	:	US
Telephone Number	:	832-458-1508
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. DEREK LIANG
Credential	:	DDS
Telephone Number	:	832-458-1508

Provider Enumeration Date	:	07/18/2015
Last Update Date	:	07/18/2015

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Directions to “IDEAL DENTAL ” Practice Location

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