Basic Information
| Provider Information | |||||||||
| NPI: | 1982089074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHACON-SMITH | ||||||||
| FirstName: | LORENA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2491 WOODBURY ST | ||||||||
| Address2: | |||||||||
| City: | PEARLAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775844801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7196606312 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 905 N GULF BLVD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775413907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2818241490 | ||||||||
| FaxNumber: | 2812206407 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2015 | ||||||||
| LastUpdateDate: | 04/06/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 31209 | TX | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 364193801 | 05 | TX | MEDICAID |