Provider Demographics
NPI:1760288781
Name:IMMA DENTAL INC
Entity type:Organization
Organization Name:IMMA DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:FRI
Authorized Official - Middle Name:
Authorized Official - Last Name:VEKUH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:936-324-1094
Mailing Address - Street 1:469 FM 1488 RD STE 103
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4189
Mailing Address - Country:US
Mailing Address - Phone:832-299-0884
Mailing Address - Fax:
Practice Address - Street 1:13843 HIGHWAY 105 W STE 106
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-5704
Practice Address - Country:US
Practice Address - Phone:936-324-1094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-20
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty