=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760053870
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILLIAM LAY DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2021
-----------------------------------------------------
Last Update Date | 07/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1810 S BOWEN RD
-----------------------------------------------------
City | PANTEGO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-3340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-274-1825
-----------------------------------------------------
Fax | 692-247-0475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1810 S BOWEN RD
-----------------------------------------------------
City | PANTEGO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76013-3340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-274-1825
-----------------------------------------------------
Fax | 682-247-0475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. WILLIAM LAY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 817-274-1825
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------