Provider Demographics
NPI:1518326750
Name:BLOSSOM ORTHODONTICS AND PEDIATRIC DENTISTRY PA
Entity Type:Organization
Organization Name:BLOSSOM ORTHODONTICS AND PEDIATRIC DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHUNDA
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-359-5551
Mailing Address - Street 1:134 VINTAGE PARK BLVD
Mailing Address - Street 2:SUITE A 109
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-3998
Mailing Address - Country:US
Mailing Address - Phone:281-359-5551
Mailing Address - Fax:
Practice Address - Street 1:13119 LOUETTA RD
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-5155
Practice Address - Country:US
Practice Address - Phone:281-359-5551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty