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General NPI Number Information
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NPI Number | 1568992261
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Entity Type | Organization
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Legal Business Name | EAST LAKE DENTAL, PLLC
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Dates
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Enumeration Date | 06/14/2017
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Last Update Date | 10/10/2017
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Provider Practice Location Address
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Address Line | 718 N BUCKNER BLVD STE 110
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City | DALLAS
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State | TX
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Zip | 75218-2764
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Country | US
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Telephone | 214-295-8440
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Fax |
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Provider Business Mailing Address
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Address Line | 718 N BUCKNER BLVD STE 110
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City | DALLAS
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State | TX
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Zip | 75218-2764
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Country | US
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Telephone | 214-295-8440
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. BRENT STEVEN DESUTTER
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Credential | DDS
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Telephone | 972-559-4185
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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