Provider Demographics
NPI:1598131575
Name:SOUTHLAKE FAMILY AND COSMETIC DENTISTRY
Entity Type:Organization
Organization Name:SOUTHLAKE FAMILY AND COSMETIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:YURA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-987-0505
Mailing Address - Street 1:9625 NORTHCROSS CENTER CT
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-7348
Mailing Address - Country:US
Mailing Address - Phone:704-987-0505
Mailing Address - Fax:704-655-8655
Practice Address - Street 1:9625 NORTHCROSS CENTER CT
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-7348
Practice Address - Country:US
Practice Address - Phone:704-987-0505
Practice Address - Fax:704-655-8655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC84391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty