MEDICARE: LAKEWOOD DENTAL ASSOCIATES, 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
2	261QD0000X	Dental Clinic/Center	27909	TX

General Provider Information

NPI Number	:	1760723381
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKEWOOD DENTAL ASSOCIATES, PLLC

Provider Business Mailing Address
First Line	:	901 NORMAL PARK DR
Second Line	:	SUITE 200
City	:	HUNTSVILLE
State	:	TX
Zip	:	77320-3770
Country	:	US
Telephone Number	:	936-689-6544
Fax Number	:

Provider Business Practice Location Address
First Line	:	901 NORMAL PARK DR
Second Line	:	SUITE 200
City	:	HUNTSVILLE
State	:	TX
Zip	:	77320-3770
Country	:	US
Telephone Number	:	936-689-6544
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	JEFFREY CLARK
Credential	:	D.M.D.
Telephone Number	:	936-689-6544

Provider Enumeration Date	:	03/06/2013
Last Update Date	:	02/14/2024

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