MEDICARE: FAV-ULOS 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	261QD0000X	Dental Clinic/Center	30122	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922588029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAV-ULOS DENTAL

Provider Business Mailing Address
First Line	:	8762 LONG POINT RD STE 102
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-3016
Country	:	US
Telephone Number	:	713-468-1400
Fax Number	:

Provider Business Practice Location Address
First Line	:	8762 LONG POINT RD STE 102
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77055-3016
Country	:	US
Telephone Number	:	713-468-1400
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	FABIOLA GARCIA DE ROCHA
Credential	:	DR
Telephone Number	:	713-468-1400

Provider Enumeration Date	:	08/17/2018
Last Update Date	:	08/17/2018

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Directions to “FAV-ULOS DENTAL ” Practice Location

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