# LAKE FAMILY AND COSMETIC DENTISTRY

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Lake Family Dental
- **Organization subpart:** No

## Provider details

- **NPI number:** 1073936084
- **Authorized official:** DR. KIMBERLY J LAKE DDS (OWNER/ PRESIDENT)
- **Authorized official phone:** (817) 263-0181

## Contact information

- **Practice address:** 4968 OVERTON RIDGE BLVD, FORT WORTH, TX 76132-1909
- **Practice address phone:** (817) 263-0181
- **Mailing address:** 4968 OVERTON RIDGE BLVD, FORT WORTH, TX 76132-1909
- **Mailing address phone:** (817) 263-0181

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 25182 | TX | Yes |

## Other

- **Enumeration date:** 01/27/2014
- **Last updated:** 01/27/2014