Provider Demographics
NPI:1992114185
Name:LULING CROSSROADS PLLC
Entity type:Organization
Organization Name:LULING CROSSROADS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMERA
Authorized Official - Middle Name:
Authorized Official - Last Name:TORRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-809-4162
Mailing Address - Street 1:409 E CROCKETT ST
Mailing Address - Street 2:
Mailing Address - City:LULING
Mailing Address - State:TX
Mailing Address - Zip Code:78648-2601
Mailing Address - Country:US
Mailing Address - Phone:830-875-3521
Mailing Address - Fax:830-875-2212
Practice Address - Street 1:409 E CROCKETT ST
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:TX
Practice Address - Zip Code:78648-2601
Practice Address - Country:US
Practice Address - Phone:830-875-3521
Practice Address - Fax:830-875-2212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty