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General NPI Number Information
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NPI Number | 1114586625
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Entity Type | Organization
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Legal Business Name | LAKESHORE PEDIATRIC DENTISTRY PLLC
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Dates
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Enumeration Date | 06/08/2019
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Last Update Date | 06/08/2019
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Provider Practice Location Address
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Address Line | 2993 MAIN ST STE 2
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City | PERU
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State | NY
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Zip | 12972-2927
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Country | US
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Telephone | 518-282-5519
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Fax |
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Provider Business Mailing Address
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Address Line | 2993 MAIN ST STE 2
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City | PERU
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State | NY
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Zip | 12972-2927
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Country | US
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Telephone | 518-282-5519
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST/OWNER
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Name | COLLEEN MARIE LACOMBE-SENECAL
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Credential | DDS
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Telephone | 518-578-5295
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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