Provider Demographics
NPI:1164390464
Name:FANTASTIC SMILES OF HOUSTON PLLC
Entity type:Organization
Organization Name:FANTASTIC SMILES OF HOUSTON PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PAYER ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-869-3789
Mailing Address - Street 1:2617 W HOLCOMBE BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-1757
Mailing Address - Country:US
Mailing Address - Phone:832-862-1111
Mailing Address - Fax:832-487-9247
Practice Address - Street 1:2617 W HOLCOMBE BLVD STE 1
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-1757
Practice Address - Country:US
Practice Address - Phone:832-862-1111
Practice Address - Fax:832-487-9247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-28
Last Update Date:2025-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty