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212 Grande Blvd Ste B226 Tyler TX 75703-4231 | |
| (903) 509-4422 | |
| (903) 509-4420 |
| Full Name | |
|---|---|
| Speciality | Dentist - Orthodontics And Dentofacial Orthopedics |
| Location | 212 Grande Blvd Ste B226, Tyler, Texas |
| Authorized Official Name and Position | Randolph William Sturrup (ORTHODONTIST) |
| Authorized Official Contact | 9035094422 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
212 Grande Blvd Ste B226 Tyler TX 75703-4231 Ph: (903) 509-4422 | 212 Grande Blvd Ste B226 Tyler TX 75703-4231 Ph: (903) 509-4422 |
| NPI Number | 1790902195 |
|---|---|
| Provider Enumeration Date | 04/19/2007 |
| Last Update Date | 08/13/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1790902195 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223X0400X | Dentist - Orthodontics And Dentofacial Orthopedics | 8352 (Texas) | Primary |
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