Provider Demographics
NPI:1407220429
Name:DENTAL BOUTIQUE PLLC
Entity Type:Organization
Organization Name:DENTAL BOUTIQUE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FARNAZ
Authorized Official - Middle Name:NICKI
Authorized Official - Last Name:TAJALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-289-2273
Mailing Address - Street 1:13630 BEAMER RD STE 112
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-6037
Mailing Address - Country:US
Mailing Address - Phone:832-289-2273
Mailing Address - Fax:281-754-4352
Practice Address - Street 1:9738 KATY FWY STE 400
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77055-6214
Practice Address - Country:US
Practice Address - Phone:832-289-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-16
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1285643692OtherNPI