Provider Demographics
NPI:1952891798
Name:TWIN LAKES DENTAL CARE PLLC
Entity Type:Organization
Organization Name:TWIN LAKES DENTAL CARE PLLC
Other - Org Name:TWIN LAKES DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:BOH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-839-6608
Mailing Address - Street 1:3127 LONG BLVD APT 308
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2077
Mailing Address - Country:US
Mailing Address - Phone:270-839-6608
Mailing Address - Fax:
Practice Address - Street 1:11315 LEBANON RD
Practice Address - Street 2:
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122
Practice Address - Country:US
Practice Address - Phone:270-839-6608
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10219261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental