Basic Information
Provider Information | |||||||||
NPI: | 1457790982 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKE CONROE DENTISTRY, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LAKE CONROE DENTISTRY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 17000 RED HILL AVE | ||||||||
Address2: |   | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 926145626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7148458890 | ||||||||
FaxNumber: | 9494741495 | ||||||||
Practice Location | |||||||||
Address1: | 3915 WEST DAVIS STREET | ||||||||
Address2: | SUITE 160 | ||||||||
City: | CONROE | ||||||||
State: | TX | ||||||||
PostalCode: | 77304 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9367602800 | ||||||||
FaxNumber: | 9367602801 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2013 | ||||||||
LastUpdateDate: | 06/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARNES | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9367602800 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.D.S. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |   |
No ID Information.