Provider Demographics
NPI:1508351016
Name:TRINITY MAGNOLIA DENTAL PLLC
Entity Type:Organization
Organization Name:TRINITY MAGNOLIA DENTAL PLLC
Other - Org Name:TRINITY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-648-7632
Mailing Address - Street 1:507 N SAM HOUSTON PKWY E STE 565
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77060-4021
Mailing Address - Country:US
Mailing Address - Phone:832-648-7632
Mailing Address - Fax:832-532-1904
Practice Address - Street 1:18640 FM 1488 RD STE I
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:TX
Practice Address - Zip Code:77354-8517
Practice Address - Country:US
Practice Address - Phone:832-648-7632
Practice Address - Fax:832-532-1904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-27
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21047122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty