Provider Demographics
NPI:1750667176
Name:SUGAR LAND DENTAL GROUP, PC
Entity Type:Organization
Organization Name:SUGAR LAND DENTAL GROUP, PC
Other - Org Name:SUGAR LAND DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTRACTS ADMIN
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:DENT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-565-0077
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:510 HWY 6
Practice Address - Street 2:SUITE 110
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478
Practice Address - Country:US
Practice Address - Phone:281-565-0077
Practice Address - Fax:281-565-1022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty