MEDICARE: LAKE FAMILY AND COSMETIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	25182	TX

General Provider Information

NPI Number	:	1073936084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE FAMILY AND COSMETIC DENTISTRY

Provider Business Mailing Address
First Line	:	4968 OVERTON RIDGE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1909
Country	:	US
Telephone Number	:	817-263-0181
Fax Number	:

Provider Business Practice Location Address
First Line	:	4968 OVERTON RIDGE BLVD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76132-1909
Country	:	US
Telephone Number	:	817-263-0181
Fax Number	:

Authorized Official
Title or Position	:	OWNER/ PRESIDENT
Name	:	DR. KIMBERLY J LAKE
Credential	:	DDS
Telephone Number	:	817-263-0181

Provider Enumeration Date	:	01/27/2014
Last Update Date	:	01/27/2014

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