MEDICARE: DENTVANCE

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	61562	CA
2	122300000X	Dentist	28644	TX

General Provider Information

NPI Number	:	1942550082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTVANCE

Provider Business Mailing Address
First Line	:	5438 NORTH FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77076-4701
Country	:	US
Telephone Number	:	818-996-2080
Fax Number	:

Provider Business Practice Location Address
First Line	:	5438 NORTH FWY
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77076-4701
Country	:	US
Telephone Number	:	818-996-2080
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	BAHMAN HAKIM
Credential	:
Telephone Number	:	818-857-6020

Provider Enumeration Date	:	09/17/2012
Last Update Date	:	03/07/2013

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Directions to “DENTVANCE ” Practice Location

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