Provider Demographics
NPI:1043612963
Name:LAKELINE FAMILY DENTAL
Entity Type:Organization
Organization Name:LAKELINE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMITA
Authorized Official - Middle Name:
Authorized Official - Last Name:PRAKASH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-659-6968
Mailing Address - Street 1:1201 N LAKELINE BLVD
Mailing Address - Street 2:SUITE NUMBER 300
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-6781
Mailing Address - Country:US
Mailing Address - Phone:512-937-3371
Mailing Address - Fax:
Practice Address - Street 1:1201 N LAKELINE BLVD
Practice Address - Street 2:SUITE NUMBER 300
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6781
Practice Address - Country:US
Practice Address - Phone:512-937-3371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22965122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183706402Medicaid