Provider Demographics
NPI:1235486275
Name:SILVER LAKE DENTAL
Entity Type:Organization
Organization Name:SILVER LAKE DENTAL
Other - Org Name:ALLEN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:HALL
Authorized Official - Last Name:NYLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-359-9950
Mailing Address - Street 1:551 W MCDERMOTT DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-2705
Mailing Address - Country:US
Mailing Address - Phone:972-359-9950
Mailing Address - Fax:972-359-6715
Practice Address - Street 1:551 W MCDERMOTT DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-2705
Practice Address - Country:US
Practice Address - Phone:972-359-9950
Practice Address - Fax:972-359-6715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX278751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty