1295132488 NPI number — LAKEVIEW MOBILE DENTAL SERVICES, PLLC

Table of content: (NPI 1295132488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295132488 NPI number — LAKEVIEW MOBILE DENTAL SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEVIEW MOBILE DENTAL SERVICES, 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:
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:
1295132488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1505 W MCDERMOTT DR
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
ALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75013-4692
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
469-675-3890
Provider Business Mailing Address Fax Number:
469-675-3893

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1505 W MCDERMOTT DR
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
ALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75013-4692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
469-675-3890
Provider Business Practice Location Address Fax Number:
469-675-3893
Provider Enumeration Date:
12/03/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MATHEW
Authorized Official First Name:
REJI
Authorized Official Middle Name:
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
469-675-3890

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  23355 , 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)

  • Identifier: 23355 . This is a "DENTAL LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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