Provider Demographics
NPI:1790569465
Name:LAKEVIEW DENTAL PLLC
Entity Type:Organization
Organization Name:LAKEVIEW DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGOLLADO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:860-679-3749
Mailing Address - Street 1:1681 MERIDEN RD
Mailing Address - Street 2:
Mailing Address - City:WOLCOTT
Mailing Address - State:CT
Mailing Address - Zip Code:06716-3322
Mailing Address - Country:US
Mailing Address - Phone:203-633-7178
Mailing Address - Fax:
Practice Address - Street 1:1681 MERIDEN RD
Practice Address - Street 2:
Practice Address - City:WOLCOTT
Practice Address - State:CT
Practice Address - Zip Code:06716-3322
Practice Address - Country:US
Practice Address - Phone:203-633-7178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty