=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194465328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUCRECIA JANE CEBALLOS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2022
-----------------------------------------------------
Last Update Date | 04/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1304 VILLAGE CREEK DR STE 400
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-4457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-480-4112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2975 BLACKBURN ST APT 1719
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-3491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-239-1724
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 38245
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------