Provider Demographics
NPI:1821472507
Name:LAKE JACKSON MODERN DENTISTRY, PC
Entity Type:Organization
Organization Name:LAKE JACKSON MODERN DENTISTRY, PC
Other - Org Name:LAKE JACKSON MODERN DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-583-6005
Mailing Address - Street 1:97 OYSTER CREEK DR SUITE 130
Mailing Address - Street 2:
Mailing Address - City:LAKE JACKSON
Mailing Address - State:TX
Mailing Address - Zip Code:77566
Mailing Address - Country:US
Mailing Address - Phone:979-583-6005
Mailing Address - Fax:979-583-6680
Practice Address - Street 1:17000 RED HILL AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-5626
Practice Address - Country:US
Practice Address - Phone:714-845-8890
Practice Address - Fax:949-474-1495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty