Provider Demographics
NPI:1619320967
Name:COUNTRY LAKES FAMILY DENTAL
Entity Type:Organization
Organization Name:COUNTRY LAKES FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:ARTHO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:940-455-7645
Mailing Address - Street 1:74 MCMAKIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BARTONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76226-8438
Mailing Address - Country:US
Mailing Address - Phone:940-455-7645
Mailing Address - Fax:
Practice Address - Street 1:74 MCMAKIN RD STE 200
Practice Address - Street 2:
Practice Address - City:BARTONVILLE
Practice Address - State:TX
Practice Address - Zip Code:76226-8438
Practice Address - Country:US
Practice Address - Phone:940-455-7645
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-21
Last Update Date:2016-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX27234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty