Provider Demographics
NPI:1568629335
Name:LAKE ERIE DENTAL INC
Entity Type:Organization
Organization Name:LAKE ERIE DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMBUCHINO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:814-734-1814
Mailing Address - Street 1:106 WATERFORD STREET
Mailing Address - Street 2:PO BOX 391
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412
Mailing Address - Country:US
Mailing Address - Phone:814-734-1814
Mailing Address - Fax:814-734-7163
Practice Address - Street 1:106 WATERFORD STREET
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412
Practice Address - Country:US
Practice Address - Phone:814-734-1814
Practice Address - Fax:814-734-7163
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKE ERIE DENTAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0313051223G0001X
PA0172241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty