Provider Demographics
NPI: | 1518317858 |
---|---|
Name: | LAKESIDE DENTAL LLC |
Entity Type: | Organization |
Organization Name: | LAKESIDE DENTAL LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OFFICE MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | DEANNA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | VILLAGRAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 414-355-5020 |
Mailing Address - Street 1: | 5600 W BROWN DEER RD |
Mailing Address - Street 2: | SUITE 111 |
Mailing Address - City: | MILWAUKEE |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 53223-2311 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 5600 W BROWN DEER RD |
Practice Address - Street 2: | SUITE 111 |
Practice Address - City: | MILWAUKEE |
Practice Address - State: | WI |
Practice Address - Zip Code: | 53223-2311 |
Practice Address - Country: | US |
Practice Address - Phone: | 414-355-5020 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2016-06-17 |
Last Update Date: | 2016-06-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 5496 | 1223G0001X |
WI | 100132615 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |