Provider Demographics
NPI:1275997082
Name:ACCESS DENTAL OF PARK LAKE PA
Entity Type:Organization
Organization Name:ACCESS DENTAL OF PARK LAKE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TIEN
Authorized Official - Middle Name:DINH
Authorized Official - Last Name:PHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-514-1689
Mailing Address - Street 1:8150 SPRINGWOOD DR # 150B
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-5810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
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:972-514-1689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-07
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22334122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty