Provider Demographics
NPI:1932361441
Name:LASER VAGINAL REJUVENATION INSTITUTE OF DALLAS PA
Entity type:Organization
Organization Name:LASER VAGINAL REJUVENATION INSTITUTE OF DALLAS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-916-4767
Mailing Address - Street 1:9101 N CENTRAL EXPY
Mailing Address - Street 2:SUITE 550
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-5927
Mailing Address - Country:US
Mailing Address - Phone:214-442-0055
Mailing Address - Fax:214-442-0056
Practice Address - Street 1:9101 N CENTRAL EXPY
Practice Address - Street 2:SUITE 550
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-5927
Practice Address - Country:US
Practice Address - Phone:214-442-0055
Practice Address - Fax:214-442-0056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8880207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0097PKOtherBCBS
TX0097PKOtherBCBS