Provider Demographics
NPI:1962760439
Name:SPROUT PEDIATRIC DENTISTRY, PINC
Entity type:Organization
Organization Name:SPROUT PEDIATRIC DENTISTRY, PINC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHUNDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:800-764-1829
Mailing Address - Street 1:9659 N SAM HOUSTON PKWY E
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-1529
Mailing Address - Country:US
Mailing Address - Phone:800-764-1829
Mailing Address - Fax:
Practice Address - Street 1:9659 N SAM HOUSTON PKWY E
Practice Address - Street 2:SUITE 103
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77396-1529
Practice Address - Country:US
Practice Address - Phone:800-764-1829
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24833122300000X, 1223P0221X
TX235641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty