1407006281 NPI number — LAKEVIEW DENTAL ASSOCIATES

Table of content: (NPI 1407006281)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407006281 NPI number — LAKEVIEW DENTAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEVIEW DENTAL ASSOCIATES
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:
1407006281
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
924 S LINCOLN AVE
Provider Second Line Business Mailing Address:
PO BOX 530
Provider Business Mailing Address City Name:
LAKEVIEW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48850-9174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-352-7294
Provider Business Mailing Address Fax Number:
989-352-8348

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
924 S LINCOLN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEVIEW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48850-9174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-352-7294
Provider Business Practice Location Address Fax Number:
989-352-8348
Provider Enumeration Date:
09/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DRAPER
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
DIANNE
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
989-352-7294

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  9226 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223G0001X , with the licence number: 18409 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: D092260 . This is a "BC BS DENTAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 195597120 . This is a "BCBS MEDICAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1955910090 . This is a "BCBS MEDICAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 124494419 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4006325 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: D184090 . This is a "BCBS DENTAL" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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