Provider Demographics
NPI:1225369077
Name:TIME SQUARE DENTAL GROUP
Entity type:Organization
Organization Name:TIME SQUARE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAZAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DACCAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-910-7779
Mailing Address - Street 1:PO BOX 460182
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77056-8182
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4450 E SAM HOUSTON PKWY S
Practice Address - Street 2:SUITE H2
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77505-3950
Practice Address - Country:US
Practice Address - Phone:713-910-7779
Practice Address - Fax:713-910-7760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190182901Medicaid