Healthcare Provider Details

I. General information

NPI: 1942436662
Provider Name (Legal Business Name): SMILEY DENTAL LAKE JUNE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10025 LAKE JUNE RD
DALLAS TX
75217-3041
US

IV. Provider business mailing address

PO BOX 453247
GARLAND TX
75045-3247
US

V. Phone/Fax

Practice location:
  • Phone: 214-718-7880
  • Fax:
Mailing address:
  • Phone: 214-718-7880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number19887
License Number StateTX

VIII. Authorized Official

Name: LYNH PHAM
Title or Position: OWNER
Credential: DDS
Phone: 214-718-7880