Provider Demographics
NPI:1215208947
Name:CULBERSON R BOREN DDS
Entity Type:Organization
Organization Name:CULBERSON R BOREN DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CULBERSON
Authorized Official - Middle Name:REEVES
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-581-2198
Mailing Address - Street 1:1634 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-3028
Mailing Address - Country:US
Mailing Address - Phone:903-581-2198
Mailing Address - Fax:903-581-9571
Practice Address - Street 1:1634 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-3028
Practice Address - Country:US
Practice Address - Phone:903-581-2198
Practice Address - Fax:903-581-9571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130631223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX008045901Medicaid