Provider Demographics
NPI:1871158907
Name:LAKE DALLAS FAMILY MEDICINE PLLC
Entity type:Organization
Organization Name:LAKE DALLAS FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:PHILLIPS
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:214-908-6012
Mailing Address - Street 1:503 MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:LAKE DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75065-2878
Mailing Address - Country:US
Mailing Address - Phone:940-535-5296
Mailing Address - Fax:940-535-5297
Practice Address - Street 1:503 MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:LAKE DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75065-2878
Practice Address - Country:US
Practice Address - Phone:940-535-5296
Practice Address - Fax:940-535-5297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-03
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty