Provider Demographics
NPI:1679070189
Name:LAKESIDE ORAL & IMPLANT SURGERY INSTITUTE, PC
Entity Type:Organization
Organization Name:LAKESIDE ORAL & IMPLANT SURGERY INSTITUTE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:773-702-1865
Mailing Address - Street 1:5841 S MARYLAND AVE # MC9020
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1443
Mailing Address - Country:US
Mailing Address - Phone:773-702-1865
Mailing Address - Fax:773-834-3888
Practice Address - Street 1:5758 S MARYLAND AVE # 4H
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1426
Practice Address - Country:US
Practice Address - Phone:773-702-1865
Practice Address - Fax:773-834-3888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021002718261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery