Provider Demographics
NPI:1235567694
Name:LAKESIDE CENTER FOR IMPLANT DENTISTRY
Entity Type:Organization
Organization Name:LAKESIDE CENTER FOR IMPLANT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-228-0909
Mailing Address - Street 1:15400 19 MILE RD
Mailing Address - Street 2:SUITE 181
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6327
Mailing Address - Country:US
Mailing Address - Phone:586-228-0909
Mailing Address - Fax:
Practice Address - Street 1:15400 19 MILE RD
Practice Address - Street 2:SUITE 181
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-6327
Practice Address - Country:US
Practice Address - Phone:586-228-0909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-23
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010132441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty