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General NPI Number Information
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NPI Number | 1023275013
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Entity Type | Organization
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Legal Business Name | LAKESHORE COMMUNITY DENTAL CLINIC
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Dates
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Enumeration Date | 05/19/2008
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Last Update Date | 05/19/2008
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Provider Practice Location Address
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Address Line | 1290 NORTH AVE LAKESHORE COMMUNITY DENTAL CLINIC
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City | CLEVELAND
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State | WI
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Zip | 53015-1412
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Country | US
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Telephone | 920-693-1386
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Fax |
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Provider Business Mailing Address
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Address Line | 1290 NORTH AVE LAKESHORE COMMUNITY DENTAL CLINIC
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City | CLEVELAND
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State | WI
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Zip | 53015-1412
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Country | US
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Telephone | 920-693-1386
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Fax |
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Authorized Official
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Title or Position | DEAN, HEALTH AND HUMAN SERVICES
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Name | MS. BARBARA J DODGE
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Credential | PH.D., R.N.
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Telephone | 920-693-1386
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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