Provider Demographics
NPI:1184022584
Name:WESTLAKE DENTAL PA
Entity Type:Organization
Organization Name:WESTLAKE DENTAL PA
Other - Org Name:SMITHSON VALLEY DENTAL PROFESSIONALS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:830-980-1800
Mailing Address - Street 1:20450 STATE HIGHWAY 46 W
Mailing Address - Street 2:SUITE 400
Mailing Address - City:SPRING BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:78070-6130
Mailing Address - Country:US
Mailing Address - Phone:830-980-1800
Mailing Address - Fax:
Practice Address - Street 1:20450 STATE HIGHWAY 46 W
Practice Address - Street 2:SUITE 400
Practice Address - City:SPRING BRANCH
Practice Address - State:TX
Practice Address - Zip Code:78070-6130
Practice Address - Country:US
Practice Address - Phone:830-980-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141201223S0112X
TX134081223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty