=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871951541
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JLS DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2016
-----------------------------------------------------
Last Update Date | 02/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 128 NACOGDOCHES ST
-----------------------------------------------------
City | CENTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75935-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 936-427-9070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 128 NACOGDOCHES ST
-----------------------------------------------------
City | CENTER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75935-3852
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. THOMAS YOUNGBLOOD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 432-553-3886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 21026
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------