Provider Demographics
NPI:1427062355
Name:BAYOU CITY DENTAL, PA
Entity type:Organization
Organization Name:BAYOU CITY DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIE
Authorized Official - Middle Name:QUYEN
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-464-9901
Mailing Address - Street 1:11723 S SAM HOUSTON PKWY E
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77089-4764
Mailing Address - Country:US
Mailing Address - Phone:281-464-9901
Mailing Address - Fax:281-464-9663
Practice Address - Street 1:11723 S SAM HOUSTON PKWY E
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77089-4764
Practice Address - Country:US
Practice Address - Phone:281-464-9901
Practice Address - Fax:281-464-9663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2008-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX198211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX174937601Medicaid