Basic Information
| Provider Information | |||||||||
| NPI: | 1306347711 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 4TH STREET DENTAL, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY SMILES OF LUBBOCK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 E MCKINNEY ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762097557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9403125626 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5709 4TH ST | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9402207833 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2018 | ||||||||
| LastUpdateDate: | 07/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | COPELAND | ||||||||
| AuthorizedOfficialFirstName: | CRIAG | ||||||||
| AuthorizedOfficialMiddleName: | FLEMING | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/DMD | ||||||||
| AuthorizedOfficialTelephone: | 9402207833 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 25735 | TX | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.