Healthcare Provider Details

I. General information

NPI: 1528423266
Provider Name (Legal Business Name): LAKE KIOWA FAMILY DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2015
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KIOWA DR W SUITE 200
LAKE KIOWA TX
76240-9584
US

IV. Provider business mailing address

100 KIOWA DR W SUITE 200
LAKE KIOWA TX
76240-9584
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number24498
License Number StateTX

VIII. Authorized Official

Name: DR. MATTHEW A BAYNE
Title or Position: DENTIST
Credential: DDS
Phone: 940-612-1555