Provider Demographics
NPI:1073936084
Name:LAKE FAMILY AND COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:LAKE FAMILY AND COSMETIC DENTISTRY
Other - Org Name:LAKE FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-263-0181
Mailing Address - Street 1:4968 OVERTON RIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-1909
Mailing Address - Country:US
Mailing Address - Phone:817-263-0181
Mailing Address - Fax:
Practice Address - Street 1:4968 OVERTON RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-1909
Practice Address - Country:US
Practice Address - Phone:817-263-0181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty