NPIMap

Organization Active NPI

Space City Pediatric Dentistry

  • Pediatric Dentistry
  • Friendswood, TX
National Provider Identifier
1487811659
Registry record updated Oct 30, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
10310 Issued in TX
Legal business name
SPACE CITY PEDIATRIC DENTISTRY
Practice address
18174 Gulf Fwy Ste 100
Friendswood, TX 77546-2722
Phone
(281) 484-7732
Fax
(888) 397-0197
NPI assigned
May 16, 2008
Last updated
Oct 30, 2023By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 30, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Bret A Ibarra, DDS, MSDNPI 1346403367
Title
Owner
Phone
(281) 484-7732

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X 10310 TX Primary

Addresses

Primary practice location

18174 Gulf Fwy Ste 100
Friendswood, TX 77546-2722

Mailing address

18174 Gulf Fwy Ste 100
Friendswood, TX 77546-2722
Phone (281) 484-7732

Other identifiers 3

IdentifierTypeStateIssuer
220062801MedicaidTX
009757801MedicaidTX
1487811659MedicaidTX

National Provider Directory

National Provider Directory

Locations

18174 Gulf Fwy
Ste 100
Friendswood, TX 77546
Phone (281) 484-7732

12700 N Featherwood Dr
Ste 290
Houston, TX 77034
Phone (281) 484-7732

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1210896000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1698624000000",
    "number": "1487811659",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18174 GULF FWY STE 100",
            "city": "FRIENDSWOOD",
            "state": "TX",
            "postal_code": "775462722",
            "telephone_number": "281-484-7732",
            "fax_number": "281-484-8751"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18174 GULF FWY STE 100",
            "city": "FRIENDSWOOD",
            "state": "TX",
            "postal_code": "775462722",
            "telephone_number": "281-484-7732",
            "fax_number": "888-397-0197"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SPACE CITY PEDIATRIC DENTISTRY",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-05-16",
        "last_updated": "2023-10-30",
        "certification_date": "2023-10-30",
        "status": "A",
        "authorized_official_last_name": "IBARRA",
        "authorized_official_first_name": "BRET",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "281-484-7732",
        "authorized_official_credential": "DDS, MSD"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "TX",
            "license": "10310",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "220062801",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "009757801",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1487811659",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Friendswood, TX

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.