Provider Demographics
NPI:1346409489
Name:NORTHWEST PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:NORTHWEST PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-583-4600
Mailing Address - Street 1:17222 RED OAK DR
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2648
Mailing Address - Country:US
Mailing Address - Phone:281-583-4600
Mailing Address - Fax:281-586-7051
Practice Address - Street 1:17222 RED OAK DR
Practice Address - Street 2:SUITE 104
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2648
Practice Address - Country:US
Practice Address - Phone:281-583-4600
Practice Address - Fax:281-586-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX203881223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1619062718Medicaid
TX1487709556Medicaid