Provider Demographics
NPI:1316324155
Name:PASADENA DENTAL & ORTHODONTICS PLLC
Entity type:Organization
Organization Name:PASADENA DENTAL & ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUYOUMDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-529-8151
Mailing Address - Street 1:1611 SPENCER HWY
Mailing Address - Street 2:C & D1
Mailing Address - City:SOUTH HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77587-3772
Mailing Address - Country:US
Mailing Address - Phone:817-529-8151
Mailing Address - Fax:817-529-8156
Practice Address - Street 1:1611 SPENCER HWY
Practice Address - Street 2:C & D1
Practice Address - City:SOUTH HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77587-3772
Practice Address - Country:US
Practice Address - Phone:817-529-8151
Practice Address - Fax:817-529-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23066122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182419510Medicaid
TX182419513Medicaid
TX182419515Medicaid
TX182419514Medicaid
TX182419517Medicaid
TX182419511Medicaid
TX182419516Medicaid