MEDICARE: LAKESIDE ORAL SURGERY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)

General Provider Information

NPI Number	:	1225732472
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE ORAL SURGERY, LLC

Provider Business Mailing Address
First Line	:	1097 LAKE OCONEE PKWY STE 101
Second Line	:
City	:	EATONTON
State	:	GA
Zip	:	31024-9510
Country	:	US
Telephone Number	:	706-916-4764
Fax Number	:

Provider Business Practice Location Address
First Line	:	1097 LAKE OCONEE PKWY STE 101
Second Line	:
City	:	EATONTON
State	:	GA
Zip	:	31024-9510
Country	:	US
Telephone Number	:	706-916-4764
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	MRS. JENNIFER TOMLINSON
Credential	:
Telephone Number	:	404-410-1340

Provider Enumeration Date	:	03/29/2023
Last Update Date	:	03/29/2023

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