Provider Demographics
NPI:1790257491
Name:LAKE TEXANA FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LAKE TEXANA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:OWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:361-782-2223
Mailing Address - Street 1:502 N WELLS ST
Mailing Address - Street 2:
Mailing Address - City:EDNA
Mailing Address - State:TX
Mailing Address - Zip Code:77957-2749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:502 N WELLS ST
Practice Address - Street 2:
Practice Address - City:EDNA
Practice Address - State:TX
Practice Address - Zip Code:77957-2749
Practice Address - Country:US
Practice Address - Phone:361-782-2223
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-19
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center