Provider Demographics
NPI:1346389814
Name:LAKESHORE MALL DENTAL GROUP
Entity Type:Organization
Organization Name:LAKESHORE MALL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIST MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-536-1957
Mailing Address - Street 1:150 PEARL NIX PKWY
Mailing Address - Street 2:SUITE B10
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3548
Mailing Address - Country:US
Mailing Address - Phone:770-536-1957
Mailing Address - Fax:770-536-3582
Practice Address - Street 1:150 PEARL NIX PKWY
Practice Address - Street 2:SUITE B10
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3548
Practice Address - Country:US
Practice Address - Phone:770-536-1957
Practice Address - Fax:770-536-3582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty