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General NPI Number Information
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NPI Number | 1598483414
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Entity Type | Organization
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Legal Business Name | LAKESIDE DENTAL SURGERY CENTER LLC
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Dates
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Enumeration Date | 08/16/2022
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Last Update Date | 11/05/2024
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Provider Practice Location Address
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Address Line | 9143 PHILIPS HWY STE 515
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City | JACKSONVILLE
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State | FL
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Zip | 32256-1348
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Country | US
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Telephone | 904-395-7772
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Fax |
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Provider Business Mailing Address
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Address Line | 3020 HARTLEY RD STE 210
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City | JACKSONVILLE
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State | FL
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Zip | 32257-8206
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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 | PRACTICE ADMINISTRATOR
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Name | ANDREW WEAVER
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Credential |
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Telephone | 904-395-7772
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number |
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License Number State |
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