Provider Demographics
NPI:1902910920
Name:LEBO, STEVE WAYNE (D,DS)
Entity Type:Individual
Prefix:
First Name:STEVE
Middle Name:WAYNE
Last Name:LEBO
Suffix:
Gender:M
Credentials:D,DS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 OLD GRANDE BLVD.
Mailing Address - Street 2:SUITE B-224
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-509-0505
Mailing Address - Fax:
Practice Address - Street 1:212 OLD GRANDE BLVD.
Practice Address - Street 2:SUITE B-210
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-509-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX125861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX007885903Medicaid