MEDICARE: MEYER PARK DENTAL CARE

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	320700000X	Physical Disabilities Residential Treatment Facility	13474	TX

General Provider Information

NPI Number	:	1962892596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEYER PARK DENTAL CARE

Provider Business Mailing Address
First Line	:	4774 W BELLFORT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77035-3434
Country	:	US
Telephone Number	:	713-728-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4774 W BELLFORT ST
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77035-3434
Country	:	US
Telephone Number	:	713-728-9000
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN LAUTEN
Credential	:
Telephone Number	:	713-728-9000

Provider Enumeration Date	:	02/04/2015
Last Update Date	:	02/04/2015

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