Provider Demographics
NPI:1386003275
Name:SOUTH HOUSTON MINT DENTISTRY, PLLC
Entity Type:Organization
Organization Name:SOUTH HOUSTON MINT DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:SGRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-821-6468
Mailing Address - Street 1:3607 OLD SPANISH TRL
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77021-2312
Mailing Address - Country:US
Mailing Address - Phone:713-692-6468
Mailing Address - Fax:
Practice Address - Street 1:3607 OLD SPANISH TRL
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77021-2312
Practice Address - Country:US
Practice Address - Phone:713-692-6468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-19
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental