Provider Demographics
NPI:1578311593
Name:VINTAGE MODERN DENTISTRY, PC
Entity type:Organization
Organization Name:VINTAGE MODERN DENTISTRY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS
Authorized Official - Prefix:
Authorized Official - First Name:SHAHLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUSAVI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-845-8500
Mailing Address - Street 1:PO BOX 920050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75392-0050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10927 LOUETTA RD STE 240
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77070-1893
Practice Address - Country:US
Practice Address - Phone:713-885-9153
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty