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General NPI Number Information
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NPI Number | 1124417928
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Entity Type | Organization
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Legal Business Name | LAKESIDE SMILES, PLLC
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Dates
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Enumeration Date | 01/16/2015
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Last Update Date | 01/16/2015
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Provider Practice Location Address
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Address Line | 200 N MAPLE ST
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City | FENNVILLE
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State | MI
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Zip | 49408-8478
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Country | US
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Telephone | 269-561-2904
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Fax |
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Provider Business Mailing Address
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Address Line | 200 N MAPLE ST PO BOX 506
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City | FENNVILLE
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State | MI
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Zip | 49408-8478
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Country | US
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Telephone | 269-561-2904
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. MICHAEL E MEYER
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Credential | DDS
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Telephone | 269-561-2904
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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 | 13870
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License Number State | MI
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