Provider Demographics
NPI:1700130648
Name:ALGOMA LAKEVIEW DENTAL CARE, S.C.
Entity Type:Organization
Organization Name:ALGOMA LAKEVIEW DENTAL CARE, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:H
Authorized Official - Last Name:PRUST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-487-5648
Mailing Address - Street 1:1223 LAKE ST
Mailing Address - Street 2:PO BOX 275
Mailing Address - City:ALGOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54201-0275
Mailing Address - Country:US
Mailing Address - Phone:920-487-5648
Mailing Address - Fax:920-487-5658
Practice Address - Street 1:1223 LAKE ST
Practice Address - Street 2:
Practice Address - City:ALGOMA
Practice Address - State:WI
Practice Address - Zip Code:54201-1447
Practice Address - Country:US
Practice Address - Phone:920-487-5648
Practice Address - Fax:920-487-5658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty