Provider Demographics
NPI:1457787970
Name:LAKESHORE DENTAL PLLC
Entity Type:Organization
Organization Name:LAKESHORE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:VILLARREAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:972-722-9100
Mailing Address - Street 1:3045 N GOLIAD ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75087-7092
Mailing Address - Country:US
Mailing Address - Phone:972-722-9100
Mailing Address - Fax:972-722-9103
Practice Address - Street 1:3045 N GOLIAD ST
Practice Address - Street 2:SUITE 105
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-7092
Practice Address - Country:US
Practice Address - Phone:972-722-9100
Practice Address - Fax:972-722-9103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-16
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22206122300000X
TX21771122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty