Provider Demographics
NPI:1669585154
Name:LAKESHORE FAMILY DENTISTRY PA
Entity type:Organization
Organization Name:LAKESHORE FAMILY DENTISTRY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JONNI
Authorized Official - Middle Name:D
Authorized Official - Last Name:DELGRECO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-429-3348
Mailing Address - Street 1:4706 BANNING AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110
Mailing Address - Country:US
Mailing Address - Phone:651-429-3348
Mailing Address - Fax:651-429-3945
Practice Address - Street 1:4706 BANNING AVE
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110
Practice Address - Country:US
Practice Address - Phone:651-429-3348
Practice Address - Fax:651-429-3945
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN92531223G0001X
MN109941223G0001X
MN82631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty