Healthcare Provider Details

I. General information

NPI: 1679727259
Provider Name (Legal Business Name): ULTIMATE SURGICAL ASSISTING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2008
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1151 N BUCKNER BLVD SUITE 308
DALLAS TX
75218-3426
US

IV. Provider business mailing address

1151 N BUCKNER BLVD SUITE 308
DALLAS TX
75218-3426
US

V. Phone/Fax

Practice location:
  • Phone: 972-270-4800
  • Fax: 214-367-1153
Mailing address:
  • Phone: 972-270-4800
  • Fax: 214-367-1153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number667351
License Number StateTX

VIII. Authorized Official

Name: DANA DIANE LACKEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 972-270-4800