Provider Demographics
NPI:1205253473
Name:DENTAL BOULEVARD
Entity type:Organization
Organization Name:DENTAL BOULEVARD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOBO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-321-1358
Mailing Address - Street 1:7324 GASTON AVE STE 121
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75214-6159
Mailing Address - Country:US
Mailing Address - Phone:214-321-1358
Mailing Address - Fax:214-321-1359
Practice Address - Street 1:7324 GASTON AVE STE 121
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214-6159
Practice Address - Country:US
Practice Address - Phone:214-321-1358
Practice Address - Fax:214-321-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-25
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX253981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1851-603-740OtherPERSONAL NPI NUMBER