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General NPI Number Information
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NPI Number | 1215058532
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Entity Type | Organization
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Legal Business Name | LAKESHORE FAMILY DENTAL CARE SC
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Dates
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Enumeration Date | 04/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3903 DOUGLAS AVE
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City | RACINE
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State | WI
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Zip | 53402
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Country | US
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Telephone | 262-639-1272
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 044290
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City | RACINE
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State | WI
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Zip | 53404
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Country | US
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Telephone | 262-639-1272
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Fax | 262-639-8870
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Authorized Official
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Title or Position | DENTIST
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Name | DR. EDWARD J OSHIRO
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Credential | DDS
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Telephone | 262-639-1272
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 3520
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License Number State | WI
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