Provider Demographics
NPI:1558598409
Name:LAKESIDE DENTAL GROUP
Entity Type:Organization
Organization Name:LAKESIDE DENTAL GROUP
Other - Org Name:TRANSITIONAL SMILES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-753-6633
Mailing Address - Street 1:1015 N STATE ROAD 7
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-5185
Mailing Address - Country:US
Mailing Address - Phone:561-753-6633
Mailing Address - Fax:561-753-6391
Practice Address - Street 1:1015 N STATE ROAD 7
Practice Address - Street 2:SUITE B
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-5185
Practice Address - Country:US
Practice Address - Phone:561-753-6633
Practice Address - Fax:561-753-6391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN112431223G0001X
FLDN159141223G0001X
FLDN112361223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty