Provider Demographics
NPI:1497837587
Name:BOREN, CULBERSON REEVES (DDS)
Entity Type:Individual
Prefix:
First Name:CULBERSON
Middle Name:REEVES
Last Name:BOREN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7916 S BROADWAY AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5274
Mailing Address - Country:US
Mailing Address - Phone:903-581-2198
Mailing Address - Fax:903-581-9571
Practice Address - Street 1:7916 S BROADWAY AVE
Practice Address - Street 2:STE 150
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-5274
Practice Address - Country:US
Practice Address - Phone:903-581-2198
Practice Address - Fax:903-581-9571
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130631223P0221X
TX0130631223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX008045901Medicaid
TX751899269OtherTAX ID