Provider Demographics
NPI:1922119841
Name:DENTISTS AT MEMORIAL PARK
Entity Type:Organization
Organization Name:DENTISTS AT MEMORIAL PARK
Other - Org Name:DENTISTS AT MEMORIAL PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CATALINA
Authorized Official - Middle Name:CRUZ
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-861-8323
Mailing Address - Street 1:5535 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007
Mailing Address - Country:US
Mailing Address - Phone:713-861-8323
Mailing Address - Fax:713-861-2307
Practice Address - Street 1:5535 MEMORIAL DRIVE
Practice Address - Street 2:SUITE K
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007
Practice Address - Country:US
Practice Address - Phone:713-861-8323
Practice Address - Fax:713-861-2307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX214301223G0001X
TX214371223G0001X
TX224691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty