MEDICARE: DRV DENTAL CLINICS, LLC

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	261QD0000X	Dental Clinic/Center	27853	TX

General Provider Information

NPI Number	:	1841691920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRV DENTAL CLINICS, LLC

Provider Business Mailing Address
First Line	:	9540 RICHMOND AVE
Second Line	:	SUITE -B
City	:	HOUSTON
State	:	TX
Zip	:	77063-3849
Country	:	US
Telephone Number	:	713-339-3554
Fax Number	:	713-339-3564

Provider Business Practice Location Address
First Line	:	9540 RICHMOND AVE
Second Line	:	SUITE -B
City	:	HOUSTON
State	:	TX
Zip	:	77063-3849
Country	:	US
Telephone Number	:	713-339-3554
Fax Number	:	713-339-3564

Authorized Official
Title or Position	:	DENTIST
Name	:	MR. JOSEPH CHARLES RILEY
Credential	:	DMD
Telephone Number	:	713-339-3554

Provider Enumeration Date	:	09/09/2014
Last Update Date	:	09/09/2014

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