Provider Demographics
NPI:1962264226
Name:290 CROSSING DENTAL AND ORTHODONTICS PLLC
Entity type:Organization
Organization Name:290 CROSSING DENTAL AND ORTHODONTICS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFFY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOUYOUMDJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:817-529-8151
Mailing Address - Street 1:100 E 15TH ST STE 520
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-6566
Mailing Address - Country:US
Mailing Address - Phone:817-529-8151
Mailing Address - Fax:817-529-8159
Practice Address - Street 1:7844 W TIDWELL RD STE 130
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-5862
Practice Address - Country:US
Practice Address - Phone:817-529-8151
Practice Address - Fax:817-529-5159
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-23
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty