Provider Demographics
NPI:1043417991
Name:LAKE SUCCESS PERIODONTICS AND IMPLANTS P.C.
Entity Type:Organization
Organization Name:LAKE SUCCESS PERIODONTICS AND IMPLANTS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHRECK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-775-3737
Mailing Address - Street 1:1300 UNION TPKE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1759
Mailing Address - Country:US
Mailing Address - Phone:516-775-3737
Mailing Address - Fax:516-775-3736
Practice Address - Street 1:1300 UNION TPKE
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1759
Practice Address - Country:US
Practice Address - Phone:516-775-3737
Practice Address - Fax:516-775-3736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2016-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0399251223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty