Provider Demographics
NPI:1538493408
Name:LAKE FOREST DENTAL, PA
Entity Type:Organization
Organization Name:LAKE FOREST DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ESMERALDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-577-9200
Mailing Address - Street 1:1801 PRECINCT LINE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3170
Mailing Address - Country:US
Mailing Address - Phone:817-577-9200
Mailing Address - Fax:817-281-9231
Practice Address - Street 1:4987 W UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-5072
Practice Address - Country:US
Practice Address - Phone:817-577-9200
Practice Address - Fax:817-281-9231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX20467261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental