Provider Demographics
NPI:1225732472
Name:LAKESIDE ORAL SURGERY, LLC
Entity Type:Organization
Organization Name:LAKESIDE ORAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TOMLINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-410-1340
Mailing Address - Street 1:1097 LAKE OCONEE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:EATONTON
Mailing Address - State:GA
Mailing Address - Zip Code:31024-9510
Mailing Address - Country:US
Mailing Address - Phone:706-916-4764
Mailing Address - Fax:
Practice Address - Street 1:1097 LAKE OCONEE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:EATONTON
Practice Address - State:GA
Practice Address - Zip Code:31024-9510
Practice Address - Country:US
Practice Address - Phone:706-916-4764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty