Healthcare Provider Details

I. General information

NPI: 1528686748
Provider Name (Legal Business Name): LAKE CITY FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 S CANAL ST
LAKE CITY MI
49651-8865
US

IV. Provider business mailing address

213 S. CANAL ST PO BOX 719
LAKE CITY MI
49651
US

V. Phone/Fax

Practice location:
  • Phone: 231-839-2630
  • Fax: 231-839-5751
Mailing address:
  • Phone: 231-839-2630
  • Fax: 231-839-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. BETH A MARSH
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 231-839-2630