Provider Demographics
NPI:1407137151
Name:LAKESIDE DENTAL CENTER INC.
Entity Type:Organization
Organization Name:LAKESIDE DENTAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZLOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:312-842-7133
Mailing Address - Street 1:2218 S MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60616-2126
Mailing Address - Country:US
Mailing Address - Phone:312-842-7133
Mailing Address - Fax:312-842-2214
Practice Address - Street 1:2218 S MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2126
Practice Address - Country:US
Practice Address - Phone:312-842-7133
Practice Address - Fax:312-842-2214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019010535122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty