1144604166 NPI number — WEST CULEBRA DENTAL PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144604166 NPI number — WEST CULEBRA DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST CULEBRA DENTAL PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144604166
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/20/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1308 TEASLEY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76205-7946
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-717-8469
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5835 CULEBRA RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78228-4354
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-368-1495
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BOGGS
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
EARL
Authorized Official Title or Position:
CHIEF OPERATING OFFICER
Authorized Official Telephone Number:
940-368-1495

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  26562 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)