Provider Demographics
NPI:1720116601
Name:LAKEVIEW PROFESSIONAL DENTAL ASSOCIATES INC.
Entity Type:Organization
Organization Name:LAKEVIEW PROFESSIONAL DENTAL ASSOCIATES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR SECRETARY TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSLIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-346-2625
Mailing Address - Street 1:851 WESTPOINT DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7142
Mailing Address - Country:US
Mailing Address - Phone:907-376-4415
Mailing Address - Fax:907-373-0589
Practice Address - Street 1:851 WESTPOINT DR
Practice Address - Street 2:SUITE 112
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7142
Practice Address - Country:US
Practice Address - Phone:907-376-4415
Practice Address - Fax:907-373-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK348122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty