1356218804 NPI number — THE TOOTH LODGE

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 1356218804 NPI number — THE TOOTH LODGE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE TOOTH LODGE
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:
1356218804
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16411 WELLERS WAY
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:
77095-3937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-312-1794
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6820 FM 2920 STE 190
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77379
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
346-298-7679
Provider Business Practice Location Address Fax Number:
346-298-7680
Provider Enumeration Date:
10/20/2025

Additional Information

Authorized Official

Authorized Official Last Name:
ANSARI
Authorized Official First Name:
AFREEN
Authorized Official Middle Name:
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
346-298-7679

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)





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