Provider Demographics
NPI:1407006281
Name:LAKEVIEW DENTAL ASSOCIATES
Entity Type:Organization
Organization Name:LAKEVIEW DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-352-7294
Mailing Address - Street 1:924 S LINCOLN AVE
Mailing Address - Street 2:PO BOX 530
Mailing Address - City:LAKEVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48850-9174
Mailing Address - Country:US
Mailing Address - Phone:989-352-7294
Mailing Address - Fax:989-352-8348
Practice Address - Street 1:924 S LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-9174
Practice Address - Country:US
Practice Address - Phone:989-352-7294
Practice Address - Fax:989-352-8348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI92261223G0001X
MI184091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MID092260OtherBC BS DENTAL
MI195597120OtherBCBS MEDICAL
MI1955910090OtherBCBS MEDICAL
MI124494419Medicaid
MI4006325Medicaid
MID184090OtherBCBS DENTAL
MID092260OtherBC BS DENTAL
MI4006325Medicaid
V02860Medicare UPIN
MIP04500002Medicare PIN