Provider Demographics
NPI:1912780461
Name:RISING STARS PD LAKELINE, PLLC
Entity Type:Organization
Organization Name:RISING STARS PD LAKELINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:SERENTHES
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-684-3738
Mailing Address - Street 1:14005 N HWY 183 STE 800
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-5960
Mailing Address - Country:US
Mailing Address - Phone:512-266-7200
Mailing Address - Fax:
Practice Address - Street 1:14005 N HWY 183 STE 800
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-5960
Practice Address - Country:US
Practice Address - Phone:512-266-7200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty