Basic Information
| Provider Information | |||||||||
| NPI: | 1609865070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | REENA | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1725 CRESCENT PLAZA DR | ||||||||
| Address2: | APT #1169 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770772476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125355747 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 12626 WOODFOREST BLVD | ||||||||
| Address2: | #Z | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770153425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135900999 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 07/22/2011 | ||||||||
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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 | 122300000X | 019025741 | IL | N | Dental Providers | Dentist | 122300000X | 23742 | TX | N | Dental Providers | Dentist | 1223G0001X | 23742 | TX | Y | Dental Providers | Dentist | General Practice | 1223P0221X | 23742 | TX | N | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 163346 | 05 | IL | MEDICAID |