1023275013 NPI number — LAKESHORE COMMUNITY DENTAL CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023275013 NPI number — LAKESHORE COMMUNITY DENTAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKESHORE COMMUNITY DENTAL CLINIC
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:
6
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:
1023275013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1290 NORTH AVE
Provider Second Line Business Mailing Address:
LAKESHORE COMMUNITY DENTAL CLINIC
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53015-1412
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-693-1386
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 NORTH AVE
Provider Second Line Business Practice Location Address:
LAKESHORE COMMUNITY DENTAL CLINIC
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53015-1412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-693-1386
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
DODGE
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
DEAN, HEALTH AND HUMAN SERVICES
Authorized Official Telephone Number:
920-693-1386

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 38394700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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