Provider Demographics
NPI:1558462689
Name:LAKESIDE DENTAL
Entity Type:Organization
Organization Name:LAKESIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VANPHAPHONE
Authorized Official - Middle Name:
Authorized Official - Last Name:LINAVONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-929-3092
Mailing Address - Street 1:407 W ELDORADO PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:LITTLE ELM
Mailing Address - State:TX
Mailing Address - Zip Code:75068-5086
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407 W ELDORADO PKWY STE 140
Practice Address - Street 2:
Practice Address - City:LITTLE ELM
Practice Address - State:TX
Practice Address - Zip Code:75068-5086
Practice Address - Country:US
Practice Address - Phone:972-292-3092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty