Provider Demographics
NPI:1528557998
Name:MEMORIAL DENTAL CARE, PLLC
Entity type:Organization
Organization Name:MEMORIAL DENTAL CARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-235-4625
Mailing Address - Street 1:14441 MEMORIAL DR STE 11
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-6737
Mailing Address - Country:US
Mailing Address - Phone:281-493-1550
Mailing Address - Fax:
Practice Address - Street 1:14441 MEMORIAL DR STE 11
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-6737
Practice Address - Country:US
Practice Address - Phone:281-493-1550
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX239101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty