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General NPI Number Information
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NPI Number | 1558845099
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Entity Type | Organization
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Legal Business Name | LAKES DENTAL PLLC
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Dates
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Enumeration Date | 09/20/2018
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Last Update Date | 09/20/2018
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Provider Practice Location Address
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Address Line | 270 LAKE ST STE 5
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City | PENN YAN
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State | NY
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Zip | 14527-1832
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Country | US
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Telephone | 315-694-7901
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Fax | 315-694-7172
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Provider Business Mailing Address
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Address Line | 270 LAKE ST STE 5
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City | PENN YAN
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State | NY
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Zip | 14527-1832
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Country | US
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Telephone | 315-694-7901
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Fax | 315-694-7172
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Authorized Official
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Title or Position | CEO
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Name | DR. SIA HERSINI
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Credential | DMD
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Telephone | 914-261-1650
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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 |
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License Number State |
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