Provider Demographics
NPI:1053835488
Name:MAI VANTAGE DENTAL PLLC
Entity Type:Organization
Organization Name:MAI VANTAGE DENTAL PLLC
Other - Org Name:RESTORATION SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-613-7743
Mailing Address - Street 1:28527 TOMBALL PKWY
Mailing Address - Street 2:
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-4545
Mailing Address - Country:US
Mailing Address - Phone:713-623-1122
Mailing Address - Fax:281-907-8003
Practice Address - Street 1:28527 TOMBALL PKWY
Practice Address - Street 2:
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-4545
Practice Address - Country:US
Practice Address - Phone:832-613-7743
Practice Address - Fax:281-907-8003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-27
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX281601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3093486-13Medicaid
TX3728164-01Medicaid