MEDICARE: 13650 EASTLAKE PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1427829589
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	13650 EASTLAKE PLLC

Provider Business Mailing Address
First Line	:	10510 MONTWOOD DR STE B
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79935-2717
Country	:	US
Telephone Number	:	915-219-4713
Fax Number	:

Provider Business Practice Location Address
First Line	:	13650 EASTLAKE BLVD
Second Line	:
City	:	HORIZON CITY
State	:	TX
Zip	:	79928-7473
Country	:	US
Telephone Number	:	915-219-4713
Fax Number	:

Authorized Official
Title or Position	:	BILLING OPERATIONS MANAGER
Name	:	CASIE GARCIA
Credential	:
Telephone Number	:	915-219-4713

Provider Enumeration Date	:	01/09/2024
Last Update Date	:	01/09/2024

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