Provider Demographics
NPI:1467641373
Name:LAKESHORE PLASTIC AND RECONSTRUCTIVE SURGERY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:LAKESHORE PLASTIC AND RECONSTRUCTIVE SURGERY ASSOCIATES, P.C.
Other - Org Name:PLASTIC SURGERY ARTS OF WEST MICHIGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DODDE
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:616-738-5870
Mailing Address - Street 1:3124 N WELLNESS DRIVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8121
Mailing Address - Country:US
Mailing Address - Phone:616-738-5870
Mailing Address - Fax:616-738-5872
Practice Address - Street 1:3124 N WELLNESS DRIVE
Practice Address - Street 2:SUITE 10
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-8121
Practice Address - Country:US
Practice Address - Phone:616-738-5870
Practice Address - Fax:616-738-5872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P21630Medicare PIN