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General NPI Number Information
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NPI Number | 1871158907
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Entity Type | Organization
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Legal Business Name | LAKE DALLAS FAMILY MEDICINE PLLC
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Dates
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Enumeration Date | 05/03/2019
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Last Update Date | 06/19/2019
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Provider Practice Location Address
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Address Line | 503 MAIN ST STE C
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City | LAKE DALLAS
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State | TX
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Zip | 75065-2878
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Country | US
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Telephone | 940-535-5296
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Fax | 940-535-5297
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Provider Business Mailing Address
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Address Line | 503 MAIN ST STE C
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City | LAKE DALLAS
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State | TX
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Zip | 75065-2878
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Country | US
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Telephone | 940-535-5296
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Fax | 940-535-5297
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Authorized Official
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Title or Position | OWNER
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Name | MRS. CARMEN PHILLIPS WHITE
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Credential | FNP-BC
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Telephone | 214-908-6012
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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