Provider Demographics
NPI:1356693915
Name:LAKE CITY DENTAL SPECIALTIES, PC
Entity type:Organization
Organization Name:LAKE CITY DENTAL SPECIALTIES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WHITNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-664-7300
Mailing Address - Street 1:1322 W KATHLEEN AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7365
Mailing Address - Country:US
Mailing Address - Phone:208-664-7300
Mailing Address - Fax:208-664-7333
Practice Address - Street 1:1322 W KATHLEEN AVE STE 2
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-7365
Practice Address - Country:US
Practice Address - Phone:208-664-7300
Practice Address - Fax:208-664-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-07
Last Update Date:2012-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4420EN1223E0200X
IDD4420PE1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty