Provider Demographics
NPI:1922086370
Name:SEVEN LAKES PERIODONTICS
Entity Type:Organization
Organization Name:SEVEN LAKES PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIEGO
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASQUEZ-PLATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:810-750-3400
Mailing Address - Street 1:1100 TORREY RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3327
Mailing Address - Country:US
Mailing Address - Phone:810-750-3400
Mailing Address - Fax:
Practice Address - Street 1:1100 TORREY RD
Practice Address - Street 2:SUITE 500
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3327
Practice Address - Country:US
Practice Address - Phone:810-750-3400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI182701223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty