1558743872 NPI number — LUBBOCK DENTAL IMPLANT CENTER PLLC

Table of content: (NPI 1558743872)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558743872 NPI number — LUBBOCK DENTAL IMPLANT CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LUBBOCK DENTAL IMPLANT CENTER 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:
6
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:
1558743872
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4415 66TH ST
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
LUBBOCK
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79414-4809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
806-797-1275
Provider Business Mailing Address Fax Number:
806-797-1274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4415 66TH ST
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
LUBBOCK
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79414-4809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
806-797-1275
Provider Business Practice Location Address Fax Number:
806-797-1274
Provider Enumeration Date:
06/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
R
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
806-797-1275

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  23079 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0300X , with the licence number: 23079 , 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)





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