Healthcare Provider Details

I. General information

NPI: 1184389355
Provider Name (Legal Business Name): FULL SMILE DENTAL LAKERIDGE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 02/24/2022
Certification Date: 02/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4425 98TH ST
LUBBOCK TX
79424-5029
US

IV. Provider business mailing address

5051 S SONCY RD
AMARILLO TX
79119-6667
US

V. Phone/Fax

Practice location:
  • Phone: 806-641-1373
  • Fax: 806-353-7077
Mailing address:
  • Phone: 806-353-1055
  • Fax: 806-353-7077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER LYNN MORRIS
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 806-353-1055