Provider Demographics
NPI:1245770148
Name:FWB DENTAL
Entity Type:Organization
Organization Name:FWB DENTAL
Other - Org Name:WILLOWBROOK MALL DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VLADA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATYTSIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-955-5558
Mailing Address - Street 1:1684 WILLOWBROOK MALL
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-6027
Mailing Address - Country:US
Mailing Address - Phone:281-955-5558
Mailing Address - Fax:281-955-8763
Practice Address - Street 1:1684 WILLOWBROOK MALL
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-6027
Practice Address - Country:US
Practice Address - Phone:281-955-5558
Practice Address - Fax:281-955-8763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-27
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX304661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty