Provider Demographics
NPI:1912546672
Name:ESCOBAR PREMIER DENTAL PLLC
Entity Type:Organization
Organization Name:ESCOBAR PREMIER DENTAL PLLC
Other - Org Name:STONE LAKE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ESCOBAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-930-7856
Mailing Address - Street 1:12711 TELGE RD
Mailing Address - Street 2:STE #100
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429
Mailing Address - Country:US
Mailing Address - Phone:832-930-7856
Mailing Address - Fax:
Practice Address - Street 1:12711 TELGE RD
Practice Address - Street 2:STE #100
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429-2289
Practice Address - Country:US
Practice Address - Phone:832-930-7856
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-30
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX374067201Medicaid