Healthcare Provider Details

I. General information

NPI: 1033355649
Provider Name (Legal Business Name): ACCESS DENTAL OF LAKE JUNE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2009
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6909 LAKE JUNE RD
DALLAS TX
75217-1325
US

IV. Provider business mailing address

6909 LAKE JUNE RD
DALLAS TX
75217-1325
US

V. Phone/Fax

Practice location:
  • Phone: 214-678-9200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TIEN DINH PHAN
Title or Position: VP
Credential: DMD
Phone: 214-678-9200