MEDICARE: LAKE WORTH PEDIATRIC DENTISTRY, 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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1720661689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE WORTH PEDIATRIC DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	7109 NAVAJO TRL
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3946
Country	:	US
Telephone Number	:	817-238-6450
Fax Number	:

Provider Business Practice Location Address
First Line	:	7109 NAVAJO TRL
Second Line	:
City	:	LAKE WORTH
State	:	TX
Zip	:	76135-3946
Country	:	US
Telephone Number	:	817-238-6450
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PARTNER
Name	:	DR. MICHAEL BALL
Credential	:	DDS
Telephone Number	:	817-995-3195

Provider Enumeration Date	:	04/29/2021
Last Update Date	:	04/29/2021

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