Healthcare Provider Details

I. General information

NPI: 1790257491
Provider Name (Legal Business Name): LAKE TEXANA FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2018
Last Update Date: 08/28/2020
Certification Date: 08/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 N WELLS ST
EDNA TX
77957-2749
US

IV. Provider business mailing address

502 N WELLS ST
EDNA TX
77957-2749
US

V. Phone/Fax

Practice location:
  • Phone: 361-782-2223
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC OWEN
Title or Position: PRESIDENT
Credential: DDS
Phone: 361-782-2223