Provider Demographics
NPI:1710497474
Name:TA, MARY KIM (DDS)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:KIM
Last Name:TA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 FRY RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-5811
Mailing Address - Country:US
Mailing Address - Phone:281-463-9324
Mailing Address - Fax:281-238-5978
Practice Address - Street 1:1450 FRY RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77084-5811
Practice Address - Country:US
Practice Address - Phone:281-463-9324
Practice Address - Fax:281-238-5978
Is Sole Proprietor?:No
Enumeration Date:2017-10-09
Last Update Date:2017-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX335761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice