Provider Demographics
NPI:1558845099
Name:LAKES DENTAL PLLC
Entity Type:Organization
Organization Name:LAKES DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HERSINI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:914-261-1650
Mailing Address - Street 1:270 LAKE ST STE 5
Mailing Address - Street 2:
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1832
Mailing Address - Country:US
Mailing Address - Phone:315-694-7901
Mailing Address - Fax:315-694-7172
Practice Address - Street 1:270 LAKE ST STE 5
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1832
Practice Address - Country:US
Practice Address - Phone:315-694-7901
Practice Address - Fax:315-694-7172
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty