Provider Demographics
NPI:1144604166
Name:WEST CULEBRA DENTAL PLLC
Entity Type:Organization
Organization Name:WEST CULEBRA DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:BOGGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-368-1495
Mailing Address - Street 1:1308 TEASLEY LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76205-7946
Mailing Address - Country:US
Mailing Address - Phone:254-717-8469
Mailing Address - Fax:
Practice Address - Street 1:5835 CULEBRA RD
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-4354
Practice Address - Country:US
Practice Address - Phone:940-368-1495
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX265621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty