Provider Demographics
NPI:1689191454
Name:R. TERRY COUNCILL, DDS, PA
Entity Type:Organization
Organization Name:R. TERRY COUNCILL, DDS, PA
Other - Org Name:R. TERRY COUNCILL, DDS, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DESPORTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-376-9246
Mailing Address - Street 1:10924 GRANT RD STE 310
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77070-4445
Mailing Address - Country:US
Mailing Address - Phone:281-376-9246
Mailing Address - Fax:281-370-8398
Practice Address - Street 1:12835 LOUETTA RD
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-5207
Practice Address - Country:US
Practice Address - Phone:281-376-9246
Practice Address - Fax:281-370-8398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13448122300000X
TX28492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty