Provider Demographics
NPI:1710504592
Name:LAKEWOOD CITY CENTER DENTAL LLC
Entity Type:Organization
Organization Name:LAKEWOOD CITY CENTER DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JUNGERMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-823-3175
Mailing Address - Street 1:14865 DETROIT AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3909
Mailing Address - Country:US
Mailing Address - Phone:216-228-7950
Mailing Address - Fax:
Practice Address - Street 1:14865 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-3909
Practice Address - Country:US
Practice Address - Phone:216-228-7950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental