1366982324 NPI number — FWB DENTAL P.L.L.C.

Table of content: (NPI 1366982324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366982324 NPI number — FWB DENTAL P.L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FWB DENTAL P.L.L.C.
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:
6
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:
1366982324
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/24/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4840 SWEETWATER BLVD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUGAR LAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77479-3403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-939-9999
Provider Business Mailing Address Fax Number:
832-939-9997

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4840 SWEETWATER BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUGAR LAND
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77479-3403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-939-9999
Provider Business Practice Location Address Fax Number:
832-939-9997
Provider Enumeration Date:
02/24/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MATYTSIN
Authorized Official First Name:
VLADA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
832-939-9999

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  30466 , 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)

  • Identifier: 3685794-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3403552-05 . This is a "PERFORMING PROVIDER#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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