Provider Demographics
NPI:1457525875
Name:LAKESIDE DENTISTRY
Entity Type:Organization
Organization Name:LAKESIDE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LULU
Authorized Official - Middle Name:
Authorized Official - Last Name:GORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-282-8222
Mailing Address - Street 1:24 W SILVER LAKE DR NE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-3640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 W SILVER LAKE DR NE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-3640
Practice Address - Country:US
Practice Address - Phone:507-282-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty