Provider Demographics
NPI:1184389355
Name:FULL SMILE DENTAL LAKERIDGE, PLLC
Entity type:Organization
Organization Name:FULL SMILE DENTAL LAKERIDGE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-353-1055
Mailing Address - Street 1:5051 S SONCY RD
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79119-6667
Mailing Address - Country:US
Mailing Address - Phone:806-353-1055
Mailing Address - Fax:806-353-7077
Practice Address - Street 1:4425 98TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-5029
Practice Address - Country:US
Practice Address - Phone:806-641-1373
Practice Address - Fax:806-353-7077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-03
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty