Provider Demographics
NPI:1932658978
Name:LAKE WORTH ORTHODONTICS
Entity Type:Organization
Organization Name:LAKE WORTH ORTHODONTICS
Other - Org Name:LAKE WORTH ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:L
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:561-408-2972
Mailing Address - Street 1:6045 HAGEN RANCH RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7251
Mailing Address - Country:US
Mailing Address - Phone:561-408-2972
Mailing Address - Fax:
Practice Address - Street 1:6045 HAGEN RANCH RD
Practice Address - Street 2:SUITE 2
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33467-7251
Practice Address - Country:US
Practice Address - Phone:561-408-2972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADN16898261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental