Provider Demographics
NPI:1780962456
Name:TOMBALL FAMILY DENTAL
Entity type:Organization
Organization Name:TOMBALL FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P.C.
Authorized Official - Prefix:DR
Authorized Official - First Name:AUDRA
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:HIEMSTRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:281-389-2720
Mailing Address - Street 1:14090 FM 2920 RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77377-5549
Mailing Address - Country:US
Mailing Address - Phone:281-516-1222
Mailing Address - Fax:
Practice Address - Street 1:14060 FM 2920 RD
Practice Address - Street 2:SUITE H
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77377-5502
Practice Address - Country:US
Practice Address - Phone:281-389-2720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX247221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty