1104056910 NPI number — LAKESIDE ENDODONTICS

Table of content: (NPI 1104056910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104056910 NPI number — LAKESIDE ENDODONTICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESIDE ENDODONTICS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104056910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10025 19TH AVE SE
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
EVERETT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98208-4275
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-357-8747
Provider Business Mailing Address Fax Number:
425-337-6190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9505 19TH AVE SE STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVERETT
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98208-3843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-357-8747
Provider Business Practice Location Address Fax Number:
425-337-6190
Provider Enumeration Date:
07/15/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KRADENPOTH
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
425-357-8747

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)