Basic Information
Provider Information | |||||||||
NPI: | 1871126284 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOWES BOULEVARD FAMILY DENTISTRY, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5800 N I 35 STE 205 | ||||||||
Address2: |   | ||||||||
City: | DENTON | ||||||||
State: | TX | ||||||||
PostalCode: | 762071438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1200 LOWES BLVD STE 112 | ||||||||
Address2: |   | ||||||||
City: | KILLEEN | ||||||||
State: | TX | ||||||||
PostalCode: | 765425204 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9402207833 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/14/2020 | ||||||||
LastUpdateDate: | 02/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | EVANS | ||||||||
AuthorizedOfficialFirstName: | EVERETT | ||||||||
AuthorizedOfficialMiddleName: | CHAD | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/DENTIST | ||||||||
AuthorizedOfficialTelephone: | 9403125626 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: | 02/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.