Provider Demographics
NPI:1164111241
Name:SD PARK LAKE PLLC
Entity Type:Organization
Organization Name:SD PARK LAKE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNHTHY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:469-902-6792
Mailing Address - Street 1:PO BOX 453247
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75045-3247
Mailing Address - Country:US
Mailing Address - Phone:214-466-1400
Mailing Address - Fax:214-367-5896
Practice Address - Street 1:1925 PARK LAKE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-1682
Practice Address - Country:US
Practice Address - Phone:254-221-0999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty