Provider Demographics
NPI:1003231242
Name:LWL DENTAL GROUP, PLLC
Entity type:Organization
Organization Name:LWL DENTAL GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:K
Authorized Official - Last Name:PETROPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-886-4688
Mailing Address - Street 1:24441 KATY FWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-1376
Mailing Address - Country:US
Mailing Address - Phone:832-886-4688
Mailing Address - Fax:
Practice Address - Street 1:24441 KATY FWY
Practice Address - Street 2:SUITE 200
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-1376
Practice Address - Country:US
Practice Address - Phone:832-886-4688
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-25
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX240511223G0001X
TX240651223G0001X
TX260461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty