=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205253473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTAL BOULEVARD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2014
-----------------------------------------------------
Last Update Date | 03/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7324 GASTON AVE STE 121
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75214-6159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-321-1358
-----------------------------------------------------
Fax | 214-321-1359
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7324 GASTON AVE STE 121
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75214-6159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-321-1358
-----------------------------------------------------
Fax | 214-321-1359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. STEPHANIE LOBO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 214-321-1358
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 25398
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------