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Organization
SOUTHLAKE DENTAL CORP
Active
Organization
SOUTHLAKE DENTAL CORP
Active
Other names
Dwain E Matelski DDS Periodontist
Organization subpart
No
Provider details
NPI number
Authorized official
DWAIN EDWIN MATELSKI (PRESIDENT)
(817) 336-1166
Entity
Organization
Contact information
Practice address
1124 S LAKE STREET, SUITE B, FORT WORTH, TX 76104
(817) 336-1166
(817) 336-1180
Mailing address
1124 S LAKE STREET, SUITE B, FORT WORTH, TX 76104
(817) 336-1166
(817) 336-1180
Taxonomy
Speciality
Code
Description
License number
State
1223P0300X
Periodontics
Primary
9930
TX
Other
Enumeration date
04/11/2007
Last updated
08/22/2020
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