Provider Demographics
NPI:1164711610
Name:ENVISION DENTAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:ENVISION DENTAL PROFESSIONAL CORPORATION
Other - Org Name:BRACES PLUS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSITA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMIDI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-733-3381
Mailing Address - Street 1:10175 WESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043-4401
Mailing Address - Country:US
Mailing Address - Phone:281-733-3381
Mailing Address - Fax:
Practice Address - Street 1:10175 WESTVIEW DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77043-4401
Practice Address - Country:US
Practice Address - Phone:281-733-3381
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24075122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty