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General NPI Number Information
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NPI Number | 1205288982
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Entity Type | Organization
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Legal Business Name | LAKESIDE ORAL & FACIAL SURGERY INSTITUTE
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Dates
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Enumeration Date | 07/06/2016
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Last Update Date | 04/19/2018
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Provider Practice Location Address
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Address Line | 2500 RIDGE AVE SUITE 302
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City | EVANSTON
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State | IL
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Zip | 60201-2455
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Country | US
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Telephone | 847-328-8899
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Fax | 847-563-1350
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Provider Business Mailing Address
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Address Line | 2500 RIDGE AVE SUITE 302
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City | EVANSTON
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State | IL
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Zip | 60201-2455
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Country | US
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Telephone | 847-328-8899
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Fax | 847-563-1350
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Authorized Official
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Title or Position | ORAL & MAXILLOFACIAL SURGEON
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Name | DR. ALAN HARVEY
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Credential | DMD
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Telephone | 847-328-8899
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | 021002718
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License Number State | IL
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