Provider Demographics
NPI:1962472373
Name:DCP OF MICHIGAN (LAKESIDE), P.C.
Entity Type:Organization
Organization Name:DCP OF MICHIGAN (LAKESIDE), P.C.
Other - Org Name:DENTALWORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-296-1943
Mailing Address - Street 1:PO BOX 860036
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55486
Mailing Address - Country:US
Mailing Address - Phone:216-584-1000
Mailing Address - Fax:216-332-7503
Practice Address - Street 1:14100 LAKESIDE CIR
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1322
Practice Address - Country:US
Practice Address - Phone:586-566-9916
Practice Address - Fax:216-584-1046
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTALONE PARTNERS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-26
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223E0200X, 1223P0221X, 1223P0300X, 1223P0700X, 1223X0400X
MI29010156721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty