Provider Demographics
NPI:1265839344
Name:FM KATY DENTAL AND ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:FM KATY DENTAL AND ORTHODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUYOUMDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-529-8151
Mailing Address - Street 1:20403 FM 529 ROAD
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77433
Mailing Address - Country:US
Mailing Address - Phone:817-529-8151
Mailing Address - Fax:817-529-8156
Practice Address - Street 1:100 E 15TH STE 520
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102
Practice Address - Country:US
Practice Address - Phone:817-529-8151
Practice Address - Fax:817-529-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23066122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182419513Medicaid
TX182419511Medicaid
TX182419514Medicaid
TX182419515Medicaid
TX182419510Medicaid