Provider Demographics
NPI:1447407739
Name:LAKESIDE DENTAL
Entity Type:Organization
Organization Name:LAKESIDE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-764-0307
Mailing Address - Street 1:1708 SOUTH CLOVER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MOSES LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98837
Mailing Address - Country:US
Mailing Address - Phone:509-764-0307
Mailing Address - Fax:509-764-0886
Practice Address - Street 1:1708 SOUTH CLOVER DRIVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837
Practice Address - Country:US
Practice Address - Phone:509-764-0307
Practice Address - Fax:509-764-0886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000108501223G0001X
WADE600288021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5056627Medicaid