Provider Demographics
NPI:1326315136
Name:LANTANA FAMILY DENTISTRY, PA
Entity Type:Organization
Organization Name:LANTANA FAMILY DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:K
Authorized Official - Last Name:CLEVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:940-455-7004
Mailing Address - Street 1:4110 FM 407
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75077-7269
Mailing Address - Country:US
Mailing Address - Phone:940-455-7004
Mailing Address - Fax:940-455-7064
Practice Address - Street 1:4110 FM 407
Practice Address - Street 2:SUITE 150
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75077-7269
Practice Address - Country:US
Practice Address - Phone:940-455-7004
Practice Address - Fax:940-455-7064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty