Provider Demographics
NPI:1952824468
Name:CLEBURNE DENTAL STUDIO PLLC
Entity Type:Organization
Organization Name:CLEBURNE DENTAL STUDIO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:817-522-3166
Mailing Address - Street 1:1607 W HENDERSON ST STE K
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76033-4179
Mailing Address - Country:US
Mailing Address - Phone:817-522-3166
Mailing Address - Fax:
Practice Address - Street 1:1607 W HENDERSON ST STE K
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-4179
Practice Address - Country:US
Practice Address - Phone:817-522-3166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX297921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3427577Medicaid