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  7. NPI Record 1750604211

EAST TEXAS DENTAL ASSOCIATES, P.A.
Complete NPI Record 1750604211
Dentist in Tyler, TX

NPI Status: Active since March 11, 2010

Contact Information

212 OLD GRANDE BLVD
SUITE B224
TYLER, TX
ZIP 75703
Phone: (903) 509-0505
Fax: (903) 509-0506

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Table of Contents

  1. NPI
  2. Entity Type Code
  3. Employer Identification Number EIN
  4. Provider Organization Name Legal Business Name
  5. Provider First Line Business Mailing Address
  6. Provider Second Line Business Mailing Address
  7. Provider Business Mailing Address City Name
  8. Provider Business Mailing Address State Name
  9. Provider Business Mailing Address Postal Code
  10. Provider Business Mailing Address Country Code If outside U S
  11. Provider Business Mailing Address Telephone Number
  12. Provider Business Mailing Address Fax Number
  13. Provider First Line Business Practice Location Address
  14. Provider Second Line Business Practice Location Address
  15. Provider Business Practice Location Address City Name
  16. Provider Business Practice Location Address State Name
  17. Provider Business Practice Location Address Postal Code
  18. Provider Business Practice Location Address Country Code If outside U S
  19. Provider Business Practice Location Address Telephone Number
  20. Provider Business Practice Location Address Fax Number
  21. Provider Enumeration Date
  22. Last Update Date
  23. Authorized Official Last Name
  24. Authorized Official First Name
  25. Authorized Official Middle Name
  26. Authorized Official Title or Position
  27. Authorized Official Telephone Number
  28. Healthcare Provider Taxonomy Code 1
  29. Provider License Number 1
  30. Provider License Number State Code 1
  31. Healthcare Provider Primary Taxonomy Switch 1
  32. Other Provider Identifier 1
  33. Other Provider Identifier Type Code 1
  34. Other Provider Identifier State 1
  35. Other Provider Identifier Issuer 1
  36. Other Provider Identifier 2
  37. Other Provider Identifier Type Code 2
  38. Other Provider Identifier State 2
  39. Is Organization Subpart
  40. Authorized Official Name Prefix Text
  41. Authorized Official Credential Text
  42. Healthcare Provider Taxonomy Group 1

Complete NPI Dataset

This page represents the complete record for NPI 1750604211. You can access the complete dataset, including a full list of field names, along with their values, and definitions as recorded by the NPI registry. Each field in the NPI record is explained, highlighting its significance and the possible values it can hold.

NPI: 1750604211
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
Entity Type Code: 2
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
Employer Identification Number EIN: UNAVAIL
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified.
The name of the organization provider. If the provider is an organization, this is the legal business name.
Provider First Line Business Mailing Address: 212 OLD GRANDE BLVD
The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Second Line Business Mailing Address: SUITE B224
The second line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider second line location address’’.
Provider Business Mailing Address City Name: TYLER
The city name in the mailing address of the provider being identified.
Provider Business Mailing Address State Name: TX
The last name of the provider. If the provider is an individual, this is the legal name.
Provider Business Mailing Address Postal Code: 757034264
The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as ‘‘Provider location address postal code’’.
Provider Business Mailing Address Country Code If outside U S : US
The country code in the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address country code’’.
Provider Business Mailing Address Telephone Number: 9035090505
The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address telephone number’’.
Provider Business Mailing Address Fax Number: 9035090506
The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider location address fax number’’.
Provider First Line Business Practice Location Address: 212 OLD GRANDE BLVD
The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Second Line Business Practice Location Address: SUITE B224
The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
Provider Business Practice Location Address City Name: TYLER
The city name in the location address of the provider being identified.
Provider Business Practice Location Address State Name: TX
The State code in the location of the provider being identified.
Provider Business Practice Location Address Postal Code: 757034264
The first line mailing address of the provider being identified. This data element may contain the same information as ‘‘Provider first line location address’’.
Provider Business Practice Location Address Country Code If outside U S : US
The city name in the mailing address of the provider being identified.
Provider Business Practice Location Address Telephone Number: 9035090505
The telephone number associated with the location address of the provider being identified.
Provider Business Practice Location Address Fax Number: 9035090506
The fax number associated with the location address of the provider being identified.
Provider Enumeration Date: 3/11/2010
The date the provider was assigned a unique identifier (assigned an NPI).
Last Update Date: 3/11/2010
The date that a record was last updated or changed.
Authorized Official Last Name: LEBO
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider.
Authorized Official First Name: STEVE
The first name of the authorized official.
Authorized Official Middle Name: W
The middle name of the authorized official.
Authorized Official Title or Position: OWNER
The title or position of the authorized official.
Authorized Official Telephone Number: 9035090505
The 10-position telephone number of the authorized official.
Healthcare Provider Taxonomy Code 1: 122300000X
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Provider License Number 1: 12586
The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’.
Provider License Number State Code 1: TX
The date that a record was last updated or changed.
Healthcare Provider Primary Taxonomy Switch 1: Y
The code designating the provider’s gender if the provider is a person.
Other Provider Identifier 1: 1902910920
Code designating the provider type, classification, and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1.
Other Provider Identifier Type Code 1: 01
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 1: TX
Other Provider Identifier Issuer 1: INDIVIDUAL NPI
Other Provider Identifier 2: 007885903
Additional number currently or formerly used as an identifier for the provider being identified. This data element will be captured from the NPI application/update form.
Other Provider Identifier Type Code 2: 05
Code indicating the type of identifier currently or formerly used by the provider being identified. The codes may reflect UPIN, NSC, OSCAR, DEA, Medicaid State or PIN identification numbers. This data element will be captured from the NPI application/update form.
Other Provider Identifier State 2: TX
Is Organization Subpart: N
Authorized Official Name Prefix Text: DR.
Authorized Official Credential Text: D.D.S.
Healthcare Provider Taxonomy Group 1: 193400000X SINGLE SPECIALTY GROUP