Provider Demographics
NPI:1750604211
Name:EAST TEXAS DENTAL ASSOCIATES, P.A.
Entity type:Organization
Organization Name:EAST TEXAS DENTAL ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEBO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-509-0505
Mailing Address - Street 1:212 OLD GRANDE BLVD
Mailing Address - Street 2:SUITE B224
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4264
Mailing Address - Country:US
Mailing Address - Phone:903-509-0505
Mailing Address - Fax:903-509-0506
Practice Address - Street 1:212 OLD GRANDE BLVD
Practice Address - Street 2:SUITE B224
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4264
Practice Address - Country:US
Practice Address - Phone:903-509-0505
Practice Address - Fax:903-509-0506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12586122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX007885903Medicaid
TX1902910920OtherINDIVIDUAL NPI