Southlake Dental Corp

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

9930 Issued in TX

Legal business name

SOUTHLAKE DENTAL CORP

Practice address

1124 S Lake Street
Suite B
Fort Worth, TX 76104

Phone

(817) 336-1166

Fax

(817) 336-1180

NPI assigned

Apr 11, 2007

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dwain Edwin Matelski

Title

President

Phone

(817) 336-1166

Specialties & licenses 1

Addresses

Other names 1

• Dwain E Matelski DDS Periodontist Other name

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1176249600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1154544740",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1124 S LAKE STREET",
            "address_2": "SUITE B",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "76104",
            "telephone_number": "817-336-1166",
            "fax_number": "817-336-1180"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1124 S LAKE STREET",
            "address_2": "SUITE B",
            "city": "FORT WORTH",
            "state": "TX",
            "postal_code": "76104",
            "telephone_number": "817-336-1166",
            "fax_number": "817-336-1180"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHLAKE DENTAL CORP",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-11",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "MATELSKI",
        "authorized_official_first_name": "DWAIN",
        "authorized_official_middle_name": "EDWIN",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "817-336-1166"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "TX",
            "license": "9930",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Dwain E Matelski DDS Periodontist",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• South Texas Dental Associates, LP
• Mika Southall, SLP
• Michelle Martin Southard, DO
• Chelsey Southern, PA-C
• Southerncare Inc
• Southlake Neuromonitoring LLC
• Southlake Orthopedics & Sports Medicine, PLLC
• Southlake Premier Anesthesia, PLLC
• Southside Acupuncture, PLLC
• Southside Adult Daycare Center, Inc.

• Periodontics in Fort Worth, TX
• Providers in Fort Worth, TX by specialty
• Periodontics in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.