Provider Demographics
NPI:1275791410
Name:LAKELINE MALL FDC PA
Entity Type:Organization
Organization Name:LAKELINE MALL FDC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ARMSTRONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-328-4857
Mailing Address - Street 1:11200 LAKELINE MALL DR
Mailing Address - Street 2:STE B1
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-1502
Mailing Address - Country:US
Mailing Address - Phone:512-448-4867
Mailing Address - Fax:512-335-7668
Practice Address - Street 1:11200 LAKELINE MALL DR
Practice Address - Street 2:STE B1
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-1502
Practice Address - Country:US
Practice Address - Phone:512-448-4867
Practice Address - Fax:512-335-7668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0008481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty