Provider Demographics
NPI:1710425269
Name:SRISHTI MEHTA DDS MS PLLC
Entity Type:Organization
Organization Name:SRISHTI MEHTA DDS MS PLLC
Other - Org Name:INDIGO ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ORTHDONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SRISHTI
Authorized Official - Middle Name:
Authorized Official - Last Name:MEHTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:405-208-9618
Mailing Address - Street 1:5407 ABINGTON CREEK LN
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-4383
Mailing Address - Country:US
Mailing Address - Phone:405-208-9618
Mailing Address - Fax:
Practice Address - Street 1:7975 W GRAND PKWY S
Practice Address - Street 2:#130
Practice Address - City:RICHMOND
Practice Address - State:TX
Practice Address - Zip Code:77407-8604
Practice Address - Country:US
Practice Address - Phone:281-201-2087
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-05
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23049122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1821127762Medicaid