| NPI | 1104190594 |
|---|---|
| Doing Business As | LAKELINE MALL FAMILY DENTAL |
| Entity Type | Organization |
| Authorized Contact | BEAU D BLANKENSHIP Owner/President 210-722-9274 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1223G0001X Dentist General Practice (Licence: TX 22816) |
| Enumeration Date | 2012-03-01 |
| Last Update Date | 2012-03-01 |