Provider Demographics
NPI:1629291679
Name:KINGSLAND DENTAL GROUP, P.A.
Entity Type:Organization
Organization Name:KINGSLAND DENTAL GROUP, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:HOLMES
Authorized Official - Last Name:TISSUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-646-8888
Mailing Address - Street 1:21681 KINGSLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2512
Mailing Address - Country:US
Mailing Address - Phone:281-646-8888
Mailing Address - Fax:281-646-8885
Practice Address - Street 1:21681 KINGSLAND BLVD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-2512
Practice Address - Country:US
Practice Address - Phone:281-646-8888
Practice Address - Fax:281-646-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14823122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty