Provider Demographics
NPI:1689710139
Name:LAKE CITY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LAKE CITY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:
Authorized Official - First Name:WINDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:843-374-2021
Mailing Address - Street 1:804 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-4400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:804 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-4400
Practice Address - Country:US
Practice Address - Phone:843-374-2021
Practice Address - Fax:843-374-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC3558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9757Medicaid