1770171647 NPI number — SHADY HOLLOW DENTAL PLLC

Table of content: (NPI 1770171647)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770171647 NPI number — SHADY HOLLOW DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHADY HOLLOW DENTAL PLLC
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:
OAK PARK DENTAL
Provider Other Organization Name Type Code:
3
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:
1770171647
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3838 N SAM HOUSTON PKWY E STE 430
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77032-3418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-369-6775
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9901 BRODIE LN STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78748-5889
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-328-4900
Provider Business Practice Location Address Fax Number:
877-291-5828
Provider Enumeration Date:
01/06/2021

Additional Information

Authorized Official

Authorized Official Last Name:
RASTOGI
Authorized Official First Name:
GEETIKA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
832-369-6941

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1295967164 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com