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7916 S Broadway Ave Ste 150 Tyler TX 75703-5274 | |
| (903) 581-2198 | |
| (903) 581-9571 |
| Full Name | |
|---|---|
| Speciality | Dentist - Pediatric Dentistry |
| Location | 7916 S Broadway Ave, Tyler, Texas |
| Authorized Official Name and Position | Culberson Reeves Boren (OWNER/ DENTIST) |
| Authorized Official Contact | 9035812198 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
7916 S Broadway Ave Ste 150 Tyler TX 75703-5274 Ph: (903) 581-2198 | 7916 S Broadway Ave Ste 150 Tyler TX 75703-5274 Ph: (903) 581-2198 |
| NPI Number | 1033411962 |
|---|---|
| Provider Enumeration Date | 11/29/2010 |
| Last Update Date | 08/14/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1033411962 | NPI | - | NPPES |
| 008045901 | Medicaid | TX |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0221X | Dentist - Pediatric Dentistry | 13063 (Texas) | Primary |
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