Provider Demographics
NPI:1700532470
Name:LAKEVIEW SMILES EDGEWATER LTD
Entity Type:Organization
Organization Name:LAKEVIEW SMILES EDGEWATER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GRACE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:773-929-1150
Mailing Address - Street 1:6351 N BROADWAY ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1401
Mailing Address - Country:US
Mailing Address - Phone:312-584-0510
Mailing Address - Fax:773-929-0831
Practice Address - Street 1:6351 N BROADWAY ST UNIT A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1401
Practice Address - Country:US
Practice Address - Phone:312-584-0510
Practice Address - Fax:312-584-0541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental