Provider Demographics
NPI:1447884176
Name:CANYON LAKE DENTAL PLLC
Entity type:Organization
Organization Name:CANYON LAKE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DHAVAL
Authorized Official - Middle Name:
Authorized Official - Last Name:THAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-360-8657
Mailing Address - Street 1:9900 WESTPARK DR STE 350
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-5285
Mailing Address - Country:US
Mailing Address - Phone:903-360-8657
Mailing Address - Fax:
Practice Address - Street 1:8565 FM 2673
Practice Address - Street 2:
Practice Address - City:CANYON LAKE
Practice Address - State:TX
Practice Address - Zip Code:78133-4908
Practice Address - Country:US
Practice Address - Phone:903-360-8657
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty