Southlake Dental Corp in Fort Worth - Periodontics
Southlake Dental Corp - NPI 1154544740
Southlake Dental Corp is a Periodontics in Fort Worth, Texas. Southlake Dental Corp practices all healthcare services and medical treatments related to Periodontics. The NPI Number for Southlake Dental Corp is 1154544740. The last update date is 2020-08-22.
Southlake Dental Corp's current location address is 1124 S Lake Street, Fort Worth, Texas. You can contact this provider via phone number 8173361166 and fax number 8173361180. The mailing address for Southlake Dental Corp is 1124 S Lake Street, Fort Worth, Texas. To know further, please read the information below!
Provider Profile Detail
| Provider Organization | Southlake Dental Corp |
|---|---|
| Address | 1124 S Lake Street, Fort Worth, Texas |
| Phone Number | 8173361166 |
| Fax Number | 8173361180 |
| Sole Proprietor | -- |
| Credentials | -- |
Authorized Official
| Title or Position | PRESIDENT |
|---|---|
| Authorized Official Name | Matelski Edwin Dwain |
| Telephone Number | 8173361166 |
NPI Number Detail
| NPI Number | 1154544740 |
|---|---|
| Provider Enumeration Date | 2007-04-11 |
| Last Updated Date | 2020-08-22 |
Provider Mailing Address Detail
| Address | 1124 S Lake Street |
|---|---|
| City | Fort Worth |
| State | Texas (TX) |
| Post Code | 76104 |
| Phone Number | 8173361166 |
| Fax Number | 8173361180 |
Provider's Primary Taxonomy Detail
| Speciality | Periodontics |
|---|---|
| Taxonomy | 1223P0300X |
| Licence No | 9930 |
|
Definition: That specialty of dentistry which encompasses the prevention, diagnosis and treatment of diseases of the supporting and surrounding tissues of the teeth or their substitutes and the maintenance of the health, function and esthetics of these structure |
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What is the unique 10-digit identification code issued to Southlake Dental Corp by the Centers for Medicare & Medicaid Services?
The Southlake Dental Corp has been assigned the NPI (National Provider Identifier) 1154544740 by the Centers for Medicare & Medicaid Services (CMS). This 10-digit code serves as a unique identifier for healthcare providers.
Could you please share the complete physical location address where Southlake Dental Corp's facilities are situated?
The facilities of Southlake Dental Corp are physically located at the following address: 1124 S Lake Street, Fort Worth, TX, 76104.
What is Southlake Dental Corp's specialized area of practice, and what is the corresponding taxonomy classification code for this field?
The Southlake Dental Corp's specialized field of practice is Periodontics, and the corresponding taxonomy code that categorizes this area of specialization is 1223P0300X.
On what date did the Centers for Medicare & Medicaid Services originally issue the 1154544740 to Southlake Dental Corp?
The Centers for Medicare & Medicaid Services originally issued the 1154544740 to Southlake Dental Corp on 2007-04-11.
As of what date were the details related to Southlake Dental Corp most recently updated or revised?
The information pertaining to Southlake Dental Corp, including its address, specialty, and other relevant details, was last updated or revised on 2020-08-22.
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