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General NPI Number Information
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NPI Number | 1518317858
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Entity Type | Organization
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Legal Business Name | LAKESIDE DENTAL LLC
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Dates
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Enumeration Date | 06/17/2016
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Last Update Date | 06/17/2016
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Provider Practice Location Address
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Address Line | 5600 W BROWN DEER RD SUITE 111
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City | MILWAUKEE
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State | WI
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Zip | 53223-2311
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Country | US
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Telephone | 414-355-5020
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Fax |
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Provider Business Mailing Address
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Address Line | 5600 W BROWN DEER RD SUITE 111
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City | MILWAUKEE
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State | WI
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Zip | 53223-2311
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DEANNA VILLAGRAN
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Credential |
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Telephone | 414-355-5020
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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 | 100132615
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5496
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License Number State | WI
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