Provider Demographics
NPI:1750563847
Name:WILD SMILES DENTAL CENTER OF HOUSTON, PLLC
Entity type:Organization
Organization Name:WILD SMILES DENTAL CENTER OF HOUSTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER, LICENSING & CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:JENELL
Authorized Official - Middle Name:
Authorized Official - Last Name:STRINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-750-0343
Mailing Address - Street 1:208 W 8TH ST
Mailing Address - Street 2:SUITE 810
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3023
Mailing Address - Country:US
Mailing Address - Phone:719-562-4447
Mailing Address - Fax:719-583-1801
Practice Address - Street 1:5720 BELLAIRE BLVD STE D
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77081-5513
Practice Address - Country:US
Practice Address - Phone:713-668-5437
Practice Address - Fax:713-668-5433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX189492501Medicaid