Provider Demographics
NPI:1316564990
Name:IKIDS PEDIATRIC DENTISTRY LAKEWOOD, PLLC
Entity Type:Organization
Organization Name:IKIDS PEDIATRIC DENTISTRY LAKEWOOD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE & CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:N
Authorized Official - Last Name:AGUILAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-466-8554
Mailing Address - Street 1:2500 E BROAD ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4361
Mailing Address - Country:US
Mailing Address - Phone:817-466-8554
Mailing Address - Fax:682-273-0663
Practice Address - Street 1:2011 ABRAMS PARKWAY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75214
Practice Address - Country:US
Practice Address - Phone:469-581-9001
Practice Address - Fax:469-581-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-30
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty