Provider Demographics
NPI:1295210573
Name:LONE STAR DENTAL ANESTHESIA
Entity Type:Organization
Organization Name:LONE STAR DENTAL ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JINSOO
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-536-3972
Mailing Address - Street 1:4112 E RENNER RD
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2832
Mailing Address - Country:US
Mailing Address - Phone:972-536-3972
Mailing Address - Fax:
Practice Address - Street 1:4112 E RENNER RD
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2832
Practice Address - Country:US
Practice Address - Phone:972-536-3972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Single Specialty