Healthcare Provider Details

I. General information

NPI: 1801241922
Provider Name (Legal Business Name): LAKEVIEW DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2016
Last Update Date: 04/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W MILWAUKEE DR
COEUR D ALENE ID
83814-2236
US

IV. Provider business mailing address

801 W MILWAUKEE DR
COEUR D'ALENE ID
83814
US

V. Phone/Fax

Practice location:
  • Phone: 208-664-0884
  • Fax: 208-664-3304
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4020
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberD4020
License Number StateID

VIII. Authorized Official

Name: DR. SPENCER WIRIG
Title or Position: OWNER
Credential: DMD
Phone: 208-664-0884