MEDICARE: LAKE COUNTRY DENTAL

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	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	841904	OTHER	TX	UNITED CONCORDIA #
2	D12073	OTHER	TX	BC/BS PROVIDER #

General Provider Information

NPI Number	:	1972692556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKE COUNTRY DENTAL

Provider Business Mailing Address
First Line	:	8461 BOAT CLUB RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3607
Country	:	US
Telephone Number	:	817-236-8771
Fax Number	:	817-236-8791

Provider Business Practice Location Address
First Line	:	8461 BOAT CLUB RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76179-3607
Country	:	US
Telephone Number	:	817-236-8771
Fax Number	:	817-236-8791

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	DR. RAY D. SNIDER
Credential	:	D.D.S., P.A.
Telephone Number	:	817-236-8771

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	08/22/2020

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Directions to “LAKE COUNTRY DENTAL ” Practice Location

Language	Start Address	Practice Location

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