Provider Demographics
NPI:1467727347
Name:SOUTH HOUSTON FAMILY DENTAL
Entity Type:Organization
Organization Name:SOUTH HOUSTON FAMILY DENTAL
Other - Org Name:SOUTH HOUSTON FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PRIYA
Authorized Official - Middle Name:T
Authorized Official - Last Name:GANJU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-941-7555
Mailing Address - Street 1:701 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77587-4205
Mailing Address - Country:US
Mailing Address - Phone:713-941-7555
Mailing Address - Fax:713-951-7527
Practice Address - Street 1:701 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77587-4205
Practice Address - Country:US
Practice Address - Phone:713-941-7555
Practice Address - Fax:713-951-7527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX19772122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1578745931Medicaid