MEDICARE: LANTANA FAMILY DENTISTRY, PA

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	1223G0001X	General Practice Dentistry	21699	TX

General Provider Information

NPI Number	:	1326315136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LANTANA FAMILY DENTISTRY, PA

Provider Business Mailing Address
First Line	:	4110 FM 407
Second Line	:	SUITE 150
City	:	LEWISVILLE
State	:	TX
Zip	:	75077-7269
Country	:	US
Telephone Number	:	940-455-7004
Fax Number	:	940-455-7064

Provider Business Practice Location Address
First Line	:	4110 FM 407
Second Line	:	SUITE 150
City	:	LEWISVILLE
State	:	TX
Zip	:	75077-7269
Country	:	US
Telephone Number	:	940-455-7004
Fax Number	:	940-455-7064

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. KELLIE K CLEVELAND
Credential	:	DDS
Telephone Number	:	940-455-7004

Provider Enumeration Date	:	11/22/2011
Last Update Date	:	11/22/2011

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