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General NPI Number Information
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NPI Number | 1841750965
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Entity Type | Organization
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Legal Business Name | LAKESIDE SMILES, LLC
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Dates
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Enumeration Date | 03/24/2019
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Last Update Date | 10/16/2019
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Provider Practice Location Address
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Address Line | 7135 MINSTREL WAY STE 101
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City | COLUMBIA
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State | MD
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Zip | 21045-5293
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Country | US
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Telephone | 443-832-3305
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Fax |
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Provider Business Mailing Address
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Address Line | 11716 PINDELL CHASE DR
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City | FULTON
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State | MD
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Zip | 20759-9704
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Country | US
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Telephone | 703-943-8360
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Fax |
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Authorized Official
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Title or Position | OWNER, DENTIST
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Name | KATHY DIPASQUALE KIM
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Credential | DDS
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Telephone | 443-979-9155
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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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