Healthcare Provider Details

I. General information

NPI: 1952889404
Provider Name (Legal Business Name): LAKE KIOWA SMILES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KIOWA DR W, STE 200
LAKE KIOWA TX
76240-9502
US

IV. Provider business mailing address

100 KIOWA DR W, STE 200
LAKE KIOWA TX
76240-9502
US

V. Phone/Fax

Practice location:
  • Phone: 940-612-1555
  • Fax: 940-612-1565
Mailing address:
  • Phone: 940-612-1555
  • Fax: 940-612-1565

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number25047
License Number StateTX

VIII. Authorized Official

Name: BENJAMIN TYLER HILL
Title or Position: OWNER
Credential: DDS
Phone: 940-612-1555