Healthcare Provider Details

I. General information

NPI: 1003268608
Provider Name (Legal Business Name): LAKESIDE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15775 HIGHWAY 16 E
SHIRLEY AR
72153-8930
US

IV. Provider business mailing address

15775 HIGHWAY 16 E
SHIRLEY AR
72153-8930
US

V. Phone/Fax

Practice location:
  • Phone: 501-499-0906
  • Fax:
Mailing address:
  • Phone: 501-499-0906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4091
License Number StateAR

VIII. Authorized Official

Name: LARHONDA APATA
Title or Position: DENTIST
Credential: DDS
Phone: 501-499-0906