Provider Demographics
NPI:1225537111
Name:LYDIAN DENTAL BURNET PLLC
Entity Type:Organization
Organization Name:LYDIAN DENTAL BURNET PLLC
Other - Org Name:BURNET ROAD FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKHANAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-560-5183
Mailing Address - Street 1:5531 BURNET RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78756
Mailing Address - Country:US
Mailing Address - Phone:480-560-5183
Mailing Address - Fax:
Practice Address - Street 1:5531 BURNET RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78756
Practice Address - Country:US
Practice Address - Phone:480-560-5183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ59041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1144355629OtherNPI