Provider Demographics
NPI:1174920458
Name:AVENUE FAMILY DENTISTRY, PLLC
Entity type:Organization
Organization Name:AVENUE FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY HELAINNE
Authorized Official - Middle Name:VILLAFLOR
Authorized Official - Last Name:AUSTRIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:713-664-1800
Mailing Address - Street 1:5420 DASHWOOD DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77081-5357
Mailing Address - Country:US
Mailing Address - Phone:713-664-1800
Mailing Address - Fax:713-664-0114
Practice Address - Street 1:5420 DASHWOOD DR
Practice Address - Street 2:SUITE 300
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-5357
Practice Address - Country:US
Practice Address - Phone:713-664-1800
Practice Address - Fax:713-664-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX205063502Medicaid