Healthcare Provider Details

I. General information

NPI: 1578468591
Provider Name (Legal Business Name): LAKESIDE ENT & FACIAL PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 4TH ST NE
WATERTOWN SD
57201-6824
US

IV. Provider business mailing address

1516 4TH ST NE
WATERTOWN SD
57201-6824
US

V. Phone/Fax

Practice location:
  • Phone: 605-880-5965
  • Fax:
Mailing address:
  • Phone: 605-880-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. JERED M MANCELL
Title or Position: PHYSICIAN/MEDICAL DIRECTOR
Credential: DO
Phone: 605-880-5965