Healthcare Provider Details

I. General information

NPI: 1134285075
Provider Name (Legal Business Name): LAKEVIEW DENTAL CENTER, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LAKE SHORE DR W
ASHLAND WI
54806-1507
US

IV. Provider business mailing address

615 LAKE SHORE DR W
ASHLAND WI
54806-1507
US

V. Phone/Fax

Practice location:
  • Phone: 715-682-2811
  • Fax:
Mailing address:
  • Phone: 715-682-2811
  • Fax:

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: DR. BARRY T JACOBS
Title or Position: PRESIDENT
Credential: DDS
Phone: 715-682-2811