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General NPI Number Information
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NPI Number | 1578468591
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Entity Type | Organization
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Legal Business Name | LAKESIDE ENT & FACIAL PLASTIC SURGERY LLC
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Dates
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Enumeration Date | 10/09/2026
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Last Update Date | 10/09/2026
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Provider Practice Location Address
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Address Line | 1516 4TH ST NE
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City | WATERTOWN
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State | SD
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Zip | 57201-6824
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Country | US
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Telephone | 605-880-5965
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Fax |
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Provider Business Mailing Address
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Address Line | 1516 4TH ST NE
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City | WATERTOWN
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State | SD
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Zip | 57201-6824
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Country | US
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Telephone | 605-880-5965
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN/MEDICAL DIRECTOR
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Name | DR. JERED M MANCELL
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Credential | DO
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Telephone | 605-880-5965
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207YX0905X
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Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
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License Number |
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License Number State | NULL
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