Provider Demographics
NPI:1609062686
Name:LAKES MALL DENTAL
Entity Type:Organization
Organization Name:LAKES MALL DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:SLOANE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:954-432-5515
Mailing Address - Street 1:11401 PINES BLVD
Mailing Address - Street 2:STE 220
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-4117
Mailing Address - Country:US
Mailing Address - Phone:954-432-5515
Mailing Address - Fax:954-432-8908
Practice Address - Street 1:11401 PINES BLVD
Practice Address - Street 2:STE 220
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-4117
Practice Address - Country:US
Practice Address - Phone:954-432-5515
Practice Address - Fax:954-432-8908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2007-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental