Basic Information
| Provider Information | |||||||||
| NPI: | 1245487073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SUMMIT DENTAL CENTER LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5225 KATY FWY | ||||||||
| Address2: | SUITE #104 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770072264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8326730999 | ||||||||
| FaxNumber: | 2816572406 | ||||||||
| Practice Location | |||||||||
| Address1: | 12626 WOODFOREST BLVD | ||||||||
| Address2: | SUITE #3 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770153425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135900999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2008 | ||||||||
| LastUpdateDate: | 08/22/2008 | ||||||||
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| AuthorizedOfficialLastName: | GOMEZ | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8326730999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.