Provider Demographics
NPI:1114586625
Name:LAKESHORE PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:LAKESHORE PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LACOMBE-SENECAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:518-578-5295
Mailing Address - Street 1:2993 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:NY
Mailing Address - Zip Code:12972-2927
Mailing Address - Country:US
Mailing Address - Phone:518-282-5519
Mailing Address - Fax:
Practice Address - Street 1:2993 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NY
Practice Address - Zip Code:12972-2927
Practice Address - Country:US
Practice Address - Phone:518-282-5519
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-08
Last Update Date:2019-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty