Provider Demographics
NPI:1912572124
Name:LAKE CITY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:LAKE CITY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCH
Authorized Official - Middle Name:TY
Authorized Official - Last Name:CARPENTER-THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:231-839-2630
Mailing Address - Street 1:213 S CANAL ST
Mailing Address - Street 2:PO BOX 719
Mailing Address - City:LAKE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49651
Mailing Address - Country:US
Mailing Address - Phone:231-839-2630
Mailing Address - Fax:231-839-5751
Practice Address - Street 1:213 S CANAL ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MI
Practice Address - Zip Code:49651-8865
Practice Address - Country:US
Practice Address - Phone:231-839-2630
Practice Address - Fax:231-839-5751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-21
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI600446OtherSTATE LICENSE