Provider Demographics
NPI:1306298831
Name:STONELAKE FAMILY DENTISTRY PLLC
Entity type:Organization
Organization Name:STONELAKE FAMILY DENTISTRY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-785-2680
Mailing Address - Street 1:14550 SH 121
Mailing Address - Street 2:STE 100
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035
Mailing Address - Country:US
Mailing Address - Phone:512-785-2680
Mailing Address - Fax:866-892-0774
Practice Address - Street 1:14550 SH 121
Practice Address - Street 2:STE 100
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035
Practice Address - Country:US
Practice Address - Phone:512-785-2680
Practice Address - Fax:866-892-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-08
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX281181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1073868402OtherNPI TYPE 1