Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 36424 | TX |
Y | 1223G0001X | General Practice | 36424 | TX |
Y | 213EG0000X | General Practice | 36424 | TX |
NPI | 1003426081 |
---|---|
Provider Name | Carson Lackey |
First Address | Dallas, TX 75204-3059 |
Second Address | Garland, TX 75041-5833 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/08/2020 |
Last Update Date | 15/06/2021 |