Provider Demographics
NPI:1346540119
Name:LAKESHORE DENTAL, INC.
Entity Type:Organization
Organization Name:LAKESHORE DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOBROW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:847-835-1450
Mailing Address - Street 1:630 VERNON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-1681
Mailing Address - Country:US
Mailing Address - Phone:847-835-1450
Mailing Address - Fax:847-835-0628
Practice Address - Street 1:630 VERNON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:GLENCOE
Practice Address - State:IL
Practice Address - Zip Code:60022-1681
Practice Address - Country:US
Practice Address - Phone:847-835-1450
Practice Address - Fax:847-835-0628
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-27
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019020613122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty