Provider Demographics
NPI:1669348272
Name:LOST CREEK DENTAL TWO, PLLC
Entity type:Organization
Organization Name:LOST CREEK DENTAL TWO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-852-3326
Mailing Address - Street 1:11919 CULEBRA RD BLDG 2
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253-2102
Mailing Address - Country:US
Mailing Address - Phone:210-688-0332
Mailing Address - Fax:
Practice Address - Street 1:11919 CULEBRA RD BLDG 2
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-2102
Practice Address - Country:US
Practice Address - Phone:210-688-0332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-13
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental