1528404894 NPI number — MONTGOMERY COUNTY PERIODONTAL ASSOCIATES PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528404894 NPI number — MONTGOMERY COUNTY PERIODONTAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTGOMERY COUNTY PERIODONTAL ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528404894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/14/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 RIVER POINTE DR
Provider Second Line Business Mailing Address:
STE 110
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77304-2945
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-363-2009
Provider Business Mailing Address Fax Number:
281-367-5622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1001 MEDICAL PLAZA DR
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
THE WOODLANDS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77380-3241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-363-2009
Provider Business Practice Location Address Fax Number:
281-367-5622
Provider Enumeration Date:
05/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DWYER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
281-363-2009

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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