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General NPI Number Information
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NPI Number | 1003268608
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Entity Type | Organization
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Legal Business Name | LAKESIDE DENTAL LLC
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Dates
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Enumeration Date | 07/07/2016
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Last Update Date | 07/07/2016
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Provider Practice Location Address
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Address Line | 15775 HIGHWAY 16 E
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City | SHIRLEY
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State | AR
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Zip | 72153-8930
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Country | US
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Telephone | 501-499-0906
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Fax |
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Provider Business Mailing Address
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Address Line | 15775 HIGHWAY 16 E
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City | SHIRLEY
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State | AR
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Zip | 72153-8930
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Country | US
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Telephone | 501-499-0906
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | LARHONDA APATA
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Credential | DDS
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Telephone | 501-499-0906
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 4091
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License Number State | AR
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