=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942986476
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAKE STATE DENTAL PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2023
-----------------------------------------------------
Last Update Date | 06/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 N LAKEVIEW AVE
-----------------------------------------------------
City | STURGIS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49091-1229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-841-0871
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 519 COLUMBIA AVE
-----------------------------------------------------
City | SAINT JOSEPH
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49085-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-841-0871
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR.
-----------------------------------------------------
Name | CLAIRE STICKLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 302-841-0871
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------