Provider Demographics
NPI:1942579602
Name:LAKE GRANBURY DENTAL & ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:LAKE GRANBURY DENTAL & ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KANEIRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:214-295-6805
Mailing Address - Street 1:1200 PALUXY MEDICAL CIR STE 101
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5696
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 PALUXY MEDICAL CIR STE 101
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5696
Practice Address - Country:US
Practice Address - Phone:817-573-8338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX200621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty