Provider Demographics
NPI:1194465328
Name:JANE CEBALLOS, LUCRECIA
Entity Type:Individual
Prefix:
First Name:LUCRECIA
Middle Name:
Last Name:JANE CEBALLOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2975 BLACKBURN ST APT 1719
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-3491
Mailing Address - Country:US
Mailing Address - Phone:215-239-1724
Mailing Address - Fax:
Practice Address - Street 1:1304 VILLAGE CREEK DR STE 400
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-4457
Practice Address - Country:US
Practice Address - Phone:214-480-4112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX382451223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty