MEDICARE: 290 CROSSING DENTAL AND ORTHODONTICS PLLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1962264226
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	290 CROSSING DENTAL AND ORTHODONTICS PLLC

Provider Business Mailing Address
First Line	:	8505 FREEPORT PKWY STE 600
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-2549
Country	:	US
Telephone Number	:	817-529-8151
Fax Number	:	817-529-8159

Provider Business Practice Location Address
First Line	:	7844 W TIDWELL RD STE 130
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77040-5862
Country	:	US
Telephone Number	:	817-529-8151
Fax Number	:	817-529-5159

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RAFFY KOUYOUMDJIAN
Credential	:	DMD
Telephone Number	:	818-653-9799

Provider Enumeration Date	:	01/23/2024
Last Update Date	:	10/03/2025

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