Provider Demographics
NPI:1720661689
Name:LAKE WORTH PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:LAKE WORTH PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:817-995-3195
Mailing Address - Street 1:7109 NAVAJO TRL
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76135-3946
Mailing Address - Country:US
Mailing Address - Phone:817-238-6450
Mailing Address - Fax:
Practice Address - Street 1:7109 NAVAJO TRL
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:TX
Practice Address - Zip Code:76135-3946
Practice Address - Country:US
Practice Address - Phone:817-238-6450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty