Basic Information
| Provider Information | |||||||||
| NPI: | 1073673281 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THACH | ||||||||
| FirstName: | TEPPHANIE | ||||||||
| MiddleName: | PHIMEANS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6300 WEST LOOP S STE 650 | ||||||||
| Address2: | |||||||||
| City: | BELLAIRE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774012997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136637960 | ||||||||
| FaxNumber: | 7133498027 | ||||||||
| Practice Location | |||||||||
| Address1: | 383 GREENS RD STE A | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770601907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818723777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 07/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | DN012969 | GA | N | Dental Providers | Dentist | Pediatric Dentistry | 1223P0221X | 0023074 | TX | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 609422190A | 05 | GA | MEDICAID | 100201 | 01 | GA | AVESIS MEDICAID | OTHER | 9181147 | 01 | GA | DORAL MEDICAID | OTHER |