Provider Demographics
NPI:1346539996
Name:LAKEWAY PEDIATRIC DENTAL, PLLC
Entity Type:Organization
Organization Name:LAKEWAY PEDIATRIC DENTAL, PLLC
Other - Org Name:LONE STAR PEDIATRIC DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:512-206-2975
Mailing Address - Street 1:505 E HUNTLAND DR.
Mailing Address - Street 2:#340
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78752
Mailing Address - Country:US
Mailing Address - Phone:512-206-2975
Mailing Address - Fax:512-371-8779
Practice Address - Street 1:14058 BEE CAVES PKWY
Practice Address - Street 2:BLDG. D. SUITE B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78738
Practice Address - Country:US
Practice Address - Phone:512-402-9996
Practice Address - Fax:512-402-9986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-05
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty