| East Texas Dental Associates, P.a. | |
|
212 Old Grande Blvd Suite B224 Tyler TX 75703-4264 | |
| (903) 509-0505 | |
| (903) 509-0506 |
| Full Name | East Texas Dental Associates, P.a. |
|---|---|
| Speciality | Dentist |
| Location | 212 Old Grande Blvd, Tyler, Texas |
| Authorized Official Name and Position | Steve W Lebo (OWNER) |
| Authorized Official Contact | 9035090505 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| East Texas Dental Associates, P.a. 212 Old Grande Blvd Suite B224 Tyler TX 75703-4264 Ph: (903) 509-0505 | East Texas Dental Associates, P.a. 212 Old Grande Blvd Suite B224 Tyler TX 75703-4264 Ph: (903) 509-0505 |
| NPI Number | 1750604211 |
|---|---|
| Provider Enumeration Date | 03/11/2010 |
| Last Update Date | 03/11/2010 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1750604211 | NPI | - | NPPES |
| 007885903 | Medicaid | TX | |
| 1902910920 | Other | TX | INDIVIDUAL NPI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 12586 (Texas) | Primary |
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