East Texas Dental Group, LLC

Primary specialty

DentistTaxonomy code 122300000X

License

31033 Issued in TX

Legal business name

EAST TEXAS DENTAL GROUP, LLC

Practice address

212 Old Grande Blvd
B224
Tyler, TX 75703-4226

Phone

(903) 509-0505

Fax

(903) 509-0506

NPI assigned

Mar 24, 2016

Last updated

Mar 24, 2016By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Young T Shim, DMD

Title

Owner

Phone

(903) 509-0505

Specialties & licenses 1

Addresses

Other identifiers 1

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1458777600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1458777600000",
    "number": "1750743167",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "212 OLD GRANDE BLVD",
            "address_2": "SUITE B224",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757034226",
            "telephone_number": "903-509-0505",
            "fax_number": "903-509-0506"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "212 OLD GRANDE BLVD",
            "address_2": "B224",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757034226",
            "telephone_number": "903-509-0505",
            "fax_number": "903-509-0506"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "EAST TEXAS DENTAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-03-24",
        "last_updated": "2016-03-24",
        "status": "A",
        "authorized_official_last_name": "SHIM",
        "authorized_official_first_name": "YOUNG",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "903-509-0505",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "TX",
            "license": "31033",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "352003301",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• East Texas Alf Waterton Inn LLC
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• East Texas Center for Independent Living
• East Texas Dental Associates, P.a.
• East Texas Eating Disorder Specialists
• East Texas Eye Care Associates PLLC (Eye Care Associates of East Texas)
• East Texas Eye Care Associates PLLC (The Optical Shop)
• East Texas Family Support Clinic
• East Texas First Surgical Support PLLC

• Dentist in Tyler, TX
• Providers in Tyler, TX by specialty
• Dentist in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 24, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.