Provider Demographics
NPI:1487010591
Name:REESE DENTAL AT LAKE COUNTRY, PLLC
Entity Type:Organization
Organization Name:REESE DENTAL AT LAKE COUNTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUZ MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-500-5288
Mailing Address - Street 1:8525 BOAT CLUB ROAD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179
Mailing Address - Country:US
Mailing Address - Phone:817-500-5288
Mailing Address - Fax:
Practice Address - Street 1:8525 BOAT CLUB RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3600
Practice Address - Country:US
Practice Address - Phone:817-500-5288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty