1427146463 NPI number — WEST LAKE COLONNADE DENTAL, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427146463 NPI number — WEST LAKE COLONNADE DENTAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WEST LAKE COLONNADE DENTAL, PLLC
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:
WEST LAKE DENTAL
Provider Other Organization Name Type Code:
3
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:
1427146463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18477 W LAKE HOUSTON PKWY
Provider Second Line Business Mailing Address:
SUITE 80
Provider Business Mailing Address City Name:
HUMBLE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77346-3517
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-812-3333
Provider Business Mailing Address Fax Number:
281-812-3332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18477 W LAKE HOUSTON PKWY
Provider Second Line Business Practice Location Address:
SUITE 80
Provider Business Practice Location Address City Name:
HUMBLE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77346-3517
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-812-3333
Provider Business Practice Location Address Fax Number:
281-812-3332
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BURNETT
Authorized Official First Name:
BRANDY
Authorized Official Middle Name:
MICHELLE
Authorized Official Title or Position:
GENERAL COUNSEL
Authorized Official Telephone Number:
281-812-3333

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  21713 , 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)





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