Basic Information
| Provider Information | |||||||||
| NPI: | 1235526856 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT DENTAL CENTER, L.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1812 DURHAM DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770072256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8326730999 | ||||||||
| FaxNumber: | 2816572406 | ||||||||
| Practice Location | |||||||||
| Address1: | 6015 HILLCROFT ST | ||||||||
| Address2: | SUITE 1600 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770811019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2817473012 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2015 | ||||||||
| LastUpdateDate: | 04/21/2015 | ||||||||
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| AuthorizedOfficialLastName: | KAWAJA | ||||||||
| AuthorizedOfficialFirstName: | ESSA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DENTIST/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8326730999 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 17989 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 193400000X | 01 | TX | DENTAL | OTHER |