Provider Demographics
NPI:1346738556
Name:LAKEWOOD FAMILY DENTAL OF KOKOMO PLLC
Entity Type:Organization
Organization Name:LAKEWOOD FAMILY DENTAL OF KOKOMO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRINIVASULU
Authorized Official - Middle Name:
Authorized Official - Last Name:KAKOLLU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:732-379-0953
Mailing Address - Street 1:8777 PURDUE RD STE 115
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2302 S DIXON RD STE 125
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6429
Practice Address - Country:US
Practice Address - Phone:732-379-0953
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty