Provider Demographics
NPI:1801242995
Name:SOUTHWESTERN PERIO & IMPLANT, PLLC
Entity type:Organization
Organization Name:SOUTHWESTERN PERIO & IMPLANT, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAEBUM
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-315-2345
Mailing Address - Street 1:697 E STATE HIGHWAY 121 STE 100
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-7950
Mailing Address - Country:US
Mailing Address - Phone:972-315-2345
Mailing Address - Fax:
Practice Address - Street 1:697 E STATE HIGHWAY 121 STE 100
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-7950
Practice Address - Country:US
Practice Address - Phone:972-315-2345
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29604261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental