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General NPI Number Information
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NPI Number | 1386351062
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Entity Type | Organization
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Legal Business Name | LAKE JACKSON FAMILY DENTISTRY PLLC
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Dates
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Enumeration Date | 11/01/2022
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Last Update Date | 11/01/2022
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Provider Practice Location Address
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Address Line | 103 N DIXIE DR
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5940
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Country | US
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Telephone | 979-297-6438
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Fax |
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Provider Business Mailing Address
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Address Line | 103 N DIXIE DR
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City | LAKE JACKSON
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State | TX
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Zip | 77566-5940
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Country | US
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Telephone | 979-297-6438
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | THOMAS ELLISOR
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Credential | DDS
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Telephone | 979-297-6438
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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