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Organization
EAST TEXAS DENTAL GROUP, LLC
Active
Organization
EAST TEXAS DENTAL GROUP, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. YOUNG T SHIM DMD (OWNER)
(903) 509-0505
Entity
Organization
Contact information
Practice address
212 OLD GRANDE BLVD, B224, TYLER, TX 75703-4226
(903) 509-0505
(903) 509-0506
Mailing address
212 OLD GRANDE BLVD, SUITE B224, TYLER, TX 75703-4226
(903) 509-0505
(903) 509-0506
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
31033
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
352003301
—
TX
Enumeration date
03/24/2016
Last updated
03/24/2016
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