Provider Demographics
NPI:1629318100
Name:LAKEWOOD RANCH DENTAL ASSOCIATES INC
Entity Type:Organization
Organization Name:LAKEWOOD RANCH DENTAL ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGETER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-907-8300
Mailing Address - Street 1:6270 LAKE OSPREY DR
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34240-8425
Mailing Address - Country:US
Mailing Address - Phone:941-907-8300
Mailing Address - Fax:941-907-8206
Practice Address - Street 1:6270 LAKE OSPREY DR
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34240-8425
Practice Address - Country:US
Practice Address - Phone:941-907-8300
Practice Address - Fax:941-907-8206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-21
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL67246OtherBLUE CROSS BLUE SHIELD