Provider Demographics
NPI:1750760179
Name:VILLAGE PARK FAMILY DENTAL LLC
Entity type:Organization
Organization Name:VILLAGE PARK FAMILY DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SABA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-336-1131
Mailing Address - Street 1:12617 LOUETTA RD STE 204
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-5212
Mailing Address - Country:US
Mailing Address - Phone:281-336-1131
Mailing Address - Fax:888-433-8848
Practice Address - Street 1:12617 LOUETTA RD STE 204
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-5212
Practice Address - Country:US
Practice Address - Phone:281-336-1131
Practice Address - Fax:888-433-8848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-19
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX235081223G0001X
251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23508OtherLICENSE NUMBER