MEDICARE: MR. ANTHONY MEDICK RDH

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	124Q00000X	Dental Hygienist	15347	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	16899832	OTHER	TX	DRIVER'S LICENSE

General Provider Information

NPI Number	:	1912311218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ANTHONY MEDICK RDH

Provider Business Mailing Address
First Line	:	16418 CANYON CHASE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77095-6532
Country	:	US
Telephone Number	:	832-428-7616
Fax Number	:

Provider Business Practice Location Address
First Line	:	16418 CANYON CHASE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77095-6532
Country	:	US
Telephone Number	:	832-428-7616
Fax Number	:

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

Provider Enumeration Date	:	06/13/2014
Last Update Date	:	06/13/2014

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