Provider Demographics
NPI:1043572555
Name:FRESHSTART PRO
Entity Type:Organization
Organization Name:FRESHSTART PRO
Other - Org Name:DENTAL DESIGNERS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:S
Authorized Official - Last Name:GHATTAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,FAGD,CAGS,MS
Authorized Official - Phone:713-664-1337
Mailing Address - Street 1:4061 BELLAIRE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1121
Mailing Address - Country:US
Mailing Address - Phone:713-664-1337
Mailing Address - Fax:
Practice Address - Street 1:4061 BELLAIRE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1121
Practice Address - Country:US
Practice Address - Phone:713-664-1337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty