MEDICARE: ROYAL LANE DENTAL CENTER PLLC

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

General Provider Information

NPI Number	:	1326577990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROYAL LANE DENTAL CENTER PLLC

Provider Business Mailing Address
First Line	:	8499 GREENVILLE AVE
Second Line	:	210
City	:	DALLAS
State	:	TX
Zip	:	75231-2413
Country	:	US
Telephone Number	:	469-904-2080
Fax Number	:

Provider Business Practice Location Address
First Line	:	8499 GREENVILLE AVE STE 210
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75231-2412
Country	:	US
Telephone Number	:	614-530-1189
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	SANG PARK
Credential	:	DDS
Telephone Number	:	469-904-2080

Provider Enumeration Date	:	06/07/2017
Last Update Date	:	12/12/2017

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