MEDICARE: LAKE KIOWA FAMILY DENTAL, 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	261QD0000X	Dental Clinic/Center	24498	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1518167915	OTHER	TX	INDIVIDUAL NPI

General Provider Information

NPI Number	:	1528423266
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE KIOWA FAMILY DENTAL, PLLC

Provider Business Mailing Address
First Line	:	100 KIOWA DR W
Second Line	:	SUITE 200
City	:	LAKE KIOWA
State	:	TX
Zip	:	76240-9584
Country	:	US
Telephone Number	:	940-612-1555
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 KIOWA DR W
Second Line	:	SUITE 200
City	:	LAKE KIOWA
State	:	TX
Zip	:	76240-9584
Country	:	US
Telephone Number	:	940-612-1555
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. MATTHEW A BAYNE
Credential	:	DDS
Telephone Number	:	940-612-1555

Provider Enumeration Date	:	12/23/2015
Last Update Date	:	12/23/2015

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