Provider Demographics
NPI:1154544740
Name:SOUTHLAKE DENTAL CORP
Entity type:Organization
Organization Name:SOUTHLAKE DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DWAIN
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:MATELSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-336-1166
Mailing Address - Street 1:1124 S LAKE STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-336-1166
Mailing Address - Fax:817-336-1180
Practice Address - Street 1:1124 S LAKE STREET
Practice Address - Street 2:SUITE B
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-336-1166
Practice Address - Fax:817-336-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX99301223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty