Provider Demographics
NPI:1487704771
Name:JASMINE DENTAL AT SILVERLAKE, PA
Entity type:Organization
Organization Name:JASMINE DENTAL AT SILVERLAKE, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:HUYNH
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-993-1299
Mailing Address - Street 1:339 W PARKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FRIENDSWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77546-5424
Mailing Address - Country:US
Mailing Address - Phone:281-993-1299
Mailing Address - Fax:281-993-1960
Practice Address - Street 1:339 W PARKWOOD AVE
Practice Address - Street 2:
Practice Address - City:FRIENDSWOOD
Practice Address - State:TX
Practice Address - Zip Code:77546-5424
Practice Address - Country:US
Practice Address - Phone:281-993-1299
Practice Address - Fax:281-993-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX198201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX151114911Medicaid
TXB19820-01OtherCHIPS