Provider Demographics
NPI:1861619611
Name:STONE LAKE DENTAL
Entity type:Organization
Organization Name:STONE LAKE DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:940-692-2851
Mailing Address - Street 1:2301 MIDWESTERN PKWY
Mailing Address - Street 2:STE. #110
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76308-2344
Mailing Address - Country:US
Mailing Address - Phone:940-692-2851
Mailing Address - Fax:940-691-1520
Practice Address - Street 1:2301 MIDWESTERN PKWY
Practice Address - Street 2:STE. #110
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2344
Practice Address - Country:US
Practice Address - Phone:940-692-2851
Practice Address - Fax:940-691-1520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX189681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty