1912546672 NPI number — ESCOBAR PREMIER DENTAL PLLC

Table of content: (NPI 1912546672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912546672 NPI number — ESCOBAR PREMIER DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESCOBAR PREMIER 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:
STONE LAKE DENTISTRY
Provider Other Organization Name Type Code:
3
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:
1912546672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2126 SPRING CREEK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77017-7209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
832-549-3164
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12711 TELGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CYPRESS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77429-2289
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-549-3164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/30/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ESCOBAR
Authorized Official First Name:
CHRISTIAN
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
832-549-3164

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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