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General NPI Number Information
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NPI Number | 1558462689
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Entity Type | Organization
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Legal Business Name | LAKESIDE DENTAL
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Dates
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Enumeration Date | 09/25/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 407 W ELDORADO PKWY STE 140
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City | LITTLE ELM
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State | TX
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Zip | 75068-5086
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Country | US
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Telephone | 972-292-3092
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Fax |
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Provider Business Mailing Address
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Address Line | 407 W ELDORADO PKWY STE 140
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City | LITTLE ELM
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State | TX
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Zip | 75068-5086
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | VANPHAPHONE LINAVONG
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Credential |
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Telephone | 972-929-3092
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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