Provider Demographics
NPI:1215290697
Name:CULBERSON R BOREN DDS PA
Entity type:Organization
Organization Name:CULBERSON R BOREN DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CULBERSON
Authorized Official - Middle Name:REEVES
Authorized Official - Last Name:BOREN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-581-2198
Mailing Address - Street 1:7916 S BROADWAY AVE
Mailing Address - Street 2:STE150
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-5274
Mailing Address - Country:US
Mailing Address - Phone:903-581-2198
Mailing Address - Fax:903-581-9571
Practice Address - Street 1:705 E MARSHALL AVE
Practice Address - Street 2:MEDICAL PLAZA III
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5573
Practice Address - Country:US
Practice Address - Phone:903-581-2198
Practice Address - Fax:903-581-9571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-20
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX130631223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty