Provider Demographics
NPI:1053753764
Name:LAKELINE MALL FAMILY DENTAL
Entity type:Organization
Organization Name:LAKELINE MALL FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-390-9948
Mailing Address - Street 1:11200 LAKELINE MALL DR
Mailing Address - Street 2:SUITE B01
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-1501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11200 LAKELINE MALL DR
Practice Address - Street 2:SUITE B01
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-1501
Practice Address - Country:US
Practice Address - Phone:214-390-9948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty