Provider Demographics
NPI:1619367612
Name:HOLLYWOOD DENTIST FOUR
Entity Type:Organization
Organization Name:HOLLYWOOD DENTIST FOUR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:M
Authorized Official - Last Name:TANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-637-8000
Mailing Address - Street 1:12620 WOODFOREST BLVD STE 420A
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77015-3643
Mailing Address - Country:US
Mailing Address - Phone:713-637-8000
Mailing Address - Fax:713-637-6558
Practice Address - Street 1:12620 WOODFOREST BLVD STE 420A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77015-3643
Practice Address - Country:US
Practice Address - Phone:713-637-8000
Practice Address - Fax:713-637-6558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX301271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty