1538493408 NPI number — LAKE FOREST DENTAL, PA

Table of content: (NPI 1538493408)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538493408 NPI number — LAKE FOREST DENTAL, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE FOREST DENTAL, PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538493408
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1801 PRECINCT LINE RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
HURST
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76054-3170
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-577-9200
Provider Business Mailing Address Fax Number:
817-281-9231

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4987 W UNIVERSITY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCKINNEY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75071-5072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-577-9200
Provider Business Practice Location Address Fax Number:
817-281-9231
Provider Enumeration Date:
09/25/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MORALES
Authorized Official First Name:
ESMERALDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
817-577-9200

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  20467 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)