MEDICARE: SOUTHLAKE DENTAL CORP

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	1223P0300X	Periodontics	9930	TX

General Provider Information

NPI Number	:	1154544740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHLAKE DENTAL CORP

Provider Business Mailing Address
First Line	:	1124 S LAKE STREET
Second Line	:	SUITE B
City	:	FORT WORTH
State	:	TX
Zip	:	76104
Country	:	US
Telephone Number	:	817-336-1166
Fax Number	:	817-336-1180

Provider Business Practice Location Address
First Line	:	1124 S LAKE STREET
Second Line	:	SUITE B
City	:	FORT WORTH
State	:	TX
Zip	:	76104
Country	:	US
Telephone Number	:	817-336-1166
Fax Number	:	817-336-1180

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DWAIN EDWIN MATELSKI
Credential	:
Telephone Number	:	817-336-1166

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/22/2020

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Directions to “SOUTHLAKE DENTAL CORP ” Practice Location

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