Basic Information
| Provider Information | |||||||||
| NPI: | 1568602134 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUMMIT DENTAL CENTER LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5225 KATY FWY STE 104 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770072268 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8326730999 | ||||||||
| FaxNumber: | 2816572406 | ||||||||
| Practice Location | |||||||||
| Address1: | 4765 FM 1960 RD W STE H | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770694641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2819778999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2009 | ||||||||
| LastUpdateDate: | 02/23/2009 | ||||||||
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| AuthorizedOfficialLastName: | KAWAJA | ||||||||
| AuthorizedOfficialFirstName: | ESSA | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8326730999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| 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 | 17989 | 05 | TX | MEDICAID |