=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255112926
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKEWOOD SMILES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2023
-----------------------------------------------------
Last Update Date | 10/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11550 LOUETTA RD STE 400
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-1369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-914-4469
-----------------------------------------------------
Fax | 281-914-4569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11550 LOUETTA RD STE 400
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77070-1369
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-914-4469
-----------------------------------------------------
Fax | 281-914-4569
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DENTIST
-----------------------------------------------------
Name | DR. BENJAMIN RAFAIL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 713-397-2954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------