Provider Demographics
NPI:1093487555
Name:LAKE SHORE DENTAL GROUP PLLC
Entity Type:Organization
Organization Name:LAKE SHORE DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:WALDSCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-722-1083
Mailing Address - Street 1:4535 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-1814
Mailing Address - Country:US
Mailing Address - Phone:254-776-7622
Mailing Address - Fax:254-776-7673
Practice Address - Street 1:4535 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710
Practice Address - Country:US
Practice Address - Phone:254-776-7622
Practice Address - Fax:254-776-7673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIGHT DENTAL ASSOCIATES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty