Provider Demographics
NPI:1366500118
Name:CLARKSTON OAKS FAMILY DENTISTRY
Entity Type:Organization
Organization Name:CLARKSTON OAKS FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:KATHLEEN
Authorized Official - Last Name:LEZOTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-623-4600
Mailing Address - Street 1:6100 DIXIE HWY
Mailing Address - Street 2:#A
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-3496
Mailing Address - Country:US
Mailing Address - Phone:248-623-4600
Mailing Address - Fax:248-623-6365
Practice Address - Street 1:6100 DIXIE HWY
Practice Address - Street 2:#A
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48346-3496
Practice Address - Country:US
Practice Address - Phone:248-623-4600
Practice Address - Fax:248-623-6365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010177121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty