Basic Information
| Provider Information | |||||||||
| NPI: | 1356733794 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GULF FAMILY DENTAL PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 SHAVER ST. | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139468200 | ||||||||
| FaxNumber: | 7139468203 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 SHAVER ST | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775042601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7139468200 | ||||||||
| FaxNumber: | 7139468203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2015 | ||||||||
| LastUpdateDate: | 02/23/2015 | ||||||||
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| AuthorizedOfficialLastName: | KORONI | ||||||||
| AuthorizedOfficialFirstName: | ABDOUL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7139468200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 19896 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 0078305-02 | 05 | TX | MEDICAID | 0078305-04 | 05 | TX | MEDICAID |