Provider Demographics
NPI:1366982324
Name:FWB DENTAL P.L.L.C.
Entity type:Organization
Organization Name:FWB DENTAL P.L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VLADA
Authorized Official - Middle Name:
Authorized Official - Last Name:MATYTSIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-939-9999
Mailing Address - Street 1:4840 SWEETWATER BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-3403
Mailing Address - Country:US
Mailing Address - Phone:832-939-9999
Mailing Address - Fax:832-939-9997
Practice Address - Street 1:4840 SWEETWATER BLVD STE A
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-3403
Practice Address - Country:US
Practice Address - Phone:832-939-9999
Practice Address - Fax:832-939-9997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX304661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3685794-01Medicaid
TX3403552-05OtherPERFORMING PROVIDER#