1922119841 NPI number — DENTISTS AT MEMORIAL PARK

Table of content: (NPI 1922119841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922119841 NPI number — DENTISTS AT MEMORIAL PARK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTISTS AT MEMORIAL PARK
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:
DENTISTS AT MEMORIAL PARK
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:
1922119841
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5535 MEMORIAL DRIVE
Provider Second Line Business Mailing Address:
SUITE K
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-861-8323
Provider Business Mailing Address Fax Number:
713-861-2307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5535 MEMORIAL DRIVE
Provider Second Line Business Practice Location Address:
SUITE K
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-861-8323
Provider Business Practice Location Address Fax Number:
713-861-2307
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CATALINA
Authorized Official Middle Name:
CRUZ
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
719-861-8323

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  21430 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 21437 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 22469 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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