Provider Demographics
NPI:1568608248
Name:LAKEVILLE DENTAL GROUP. P.C.
Entity Type:Organization
Organization Name:LAKEVILLE DENTAL GROUP. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:MICHEAL
Authorized Official - Last Name:DEVITA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:516-869-3400
Mailing Address - Street 1:1 HOLLOW LN
Mailing Address - Street 2:SUITE 108
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1215
Mailing Address - Country:US
Mailing Address - Phone:516-869-3400
Mailing Address - Fax:516-869-3403
Practice Address - Street 1:1 HOLLOW LN
Practice Address - Street 2:SUITE 108
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1215
Practice Address - Country:US
Practice Address - Phone:516-869-3400
Practice Address - Fax:516-869-3403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-30
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0316971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty