Provider Demographics
NPI:1750610721
Name:LAKEVIEW DENTAL CLINIC
Entity type:Organization
Organization Name:LAKEVIEW DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEPTIONIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-751-4523
Mailing Address - Street 1:603 BEMIDJI AVE N
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-3015
Mailing Address - Country:US
Mailing Address - Phone:218-751-4523
Mailing Address - Fax:218-751-0285
Practice Address - Street 1:603 BEMIDJI AVE N
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-3015
Practice Address - Country:US
Practice Address - Phone:218-751-4523
Practice Address - Fax:218-751-0285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101181223G0001X
MN83621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1962575043Medicaid
MN1821161910Medicaid