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General NPI Number Information
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NPI Number | 1275871329
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Entity Type | Organization
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Legal Business Name | LAKE CITY DENTAL
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Dates
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Enumeration Date | 01/24/2013
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 6176 GOVERNMENT WAY
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City | COEUR D'ALENE
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State | ID
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Zip | 83815
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Country | US
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Telephone | 208-664-6476
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Fax |
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Provider Business Mailing Address
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Address Line | 6176 GOVERNMENT WAY
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City | COEUR D'ALENE
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State | ID
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Zip | 83815
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Country | US
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Telephone | 208-664-6476
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | GARY BILLS
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Credential | DDS
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Telephone | 208-664-6476
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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 |
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License Number State |
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