Provider Demographics
NPI:1275700577
Name:LAKE ERIE DENTAL, INC.
Entity Type:Organization
Organization Name:LAKE ERIE DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMBUCHINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:814-864-7511
Mailing Address - Street 1:4944 PEACH ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16509-2012
Mailing Address - Country:US
Mailing Address - Phone:814-864-7511
Mailing Address - Fax:814-866-1565
Practice Address - Street 1:4944 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2012
Practice Address - Country:US
Practice Address - Phone:814-864-7511
Practice Address - Fax:814-866-1565
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE ERIE DENTAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0313051223G0001X
PA172241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty