Provider Demographics
NPI:1508403254
Name:LUBBOCK PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:LUBBOCK PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-350-5437
Mailing Address - Street 1:2300 WOLFLIN AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1832
Mailing Address - Country:US
Mailing Address - Phone:806-350-5437
Mailing Address - Fax:
Practice Address - Street 1:6309 4TH ST STE 100
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-4281
Practice Address - Country:US
Practice Address - Phone:806-318-5241
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-02
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX406900701Medicaid