Provider Demographics
NPI:1295132488
Name:LAKEVIEW MOBILE DENTAL SERVICES, PLLC
Entity type:Organization
Organization Name:LAKEVIEW MOBILE DENTAL SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:REJI
Authorized Official - Middle Name:
Authorized Official - Last Name:MATHEW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:469-675-3890
Mailing Address - Street 1:1505 W MCDERMOTT DR
Mailing Address - Street 2:STE 200
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4692
Mailing Address - Country:US
Mailing Address - Phone:469-675-3890
Mailing Address - Fax:469-675-3893
Practice Address - Street 1:1505 W MCDERMOTT DR
Practice Address - Street 2:STE 200
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4692
Practice Address - Country:US
Practice Address - Phone:469-675-3890
Practice Address - Fax:469-675-3893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23355261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX23355OtherDENTAL LICENSE