Provider Demographics
NPI: | 1568813186 |
---|---|
Name: | AUTUMN FAMILY DENTISTRY, P.L.L.C. |
Entity Type: | Organization |
Organization Name: | AUTUMN FAMILY DENTISTRY, P.L.L.C. |
Other - Org Name: | AUTUMN FAMILY DENTISTRY |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DENTIST |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | THIEN-KIM |
Authorized Official - Middle Name: | THI |
Authorized Official - Last Name: | PHAM |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 281-678-8344 |
Mailing Address - Street 1: | 2508 GULF FWY S STE 108 |
Mailing Address - Street 2: | |
Mailing Address - City: | LEAGUE CITY |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77573-6743 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 281-678-8344 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2508 GULF FWY S STE 108 |
Practice Address - Street 2: | |
Practice Address - City: | LEAGUE CITY |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77573-6743 |
Practice Address - Country: | US |
Practice Address - Phone: | 281-678-8344 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-06-24 |
Last Update Date: | 2020-02-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental | Group - Single Specialty |