Provider Demographics
NPI:1891262804
Name:LAKESIDE DENTAL LLC
Entity Type:Organization
Organization Name:LAKESIDE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SALAMON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-310-0842
Mailing Address - Street 1:60 WILLOW LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2629
Mailing Address - Country:US
Mailing Address - Phone:207-310-0842
Mailing Address - Fax:
Practice Address - Street 1:1051 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:ME
Practice Address - Zip Code:04351-3403
Practice Address - Country:US
Practice Address - Phone:207-310-0842
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental