Provider Demographics
NPI:1124568928
Name:I TOWN MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:I TOWN MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:KWON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-407-9401
Mailing Address - Street 1:2974 LBJ FWY STE 301
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75234-7667
Mailing Address - Country:US
Mailing Address - Phone:972-407-9401
Mailing Address - Fax:844-256-5202
Practice Address - Street 1:2974 LBJ FWY STE 301
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7667
Practice Address - Country:US
Practice Address - Phone:972-407-9401
Practice Address - Fax:844-256-5202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty