Provider Demographics
NPI:1790146587
Name:WATER'S EDGE DENTAL
Entity Type:Organization
Organization Name:WATER'S EDGE DENTAL
Other - Org Name:LAKESIDE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GIEBENHAIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-475-0989
Mailing Address - Street 1:1880 W WAYZATA BLVD
Mailing Address - Street 2:P.O.BOX 128
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-9491
Mailing Address - Country:US
Mailing Address - Phone:952-475-0989
Mailing Address - Fax:952-475-2053
Practice Address - Street 1:1880 W WAYZATA BLVD
Practice Address - Street 2:
Practice Address - City:LONG LAKE
Practice Address - State:MN
Practice Address - Zip Code:55356-9491
Practice Address - Country:US
Practice Address - Phone:952-475-0989
Practice Address - Fax:952-475-2053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental