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General NPI Number Information
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NPI Number | 1962472373
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Entity Type | Organization
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Legal Business Name | DCP OF MICHIGAN (LAKESIDE), P.C.
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Dates
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Enumeration Date | 01/26/2006
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Last Update Date | 12/09/2016
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Provider Practice Location Address
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Address Line | 14100 LAKESIDE CIR
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City | STERLING HEIGHTS
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State | MI
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Zip | 48313-1322
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Country | US
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Telephone | 586-566-9916
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Fax | 216-584-1046
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Provider Business Mailing Address
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Address Line | PO BOX 860036
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City | MINNEAPOLIS
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State | MN
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Zip | 55486
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Country | US
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Telephone | 216-584-1000
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Fax | 216-332-7503
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Authorized Official
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Title or Position | DENTIST/OWNER
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Name | CHARLES SMITH
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Credential | DDS
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Telephone | 586-296-1943
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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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Taxonomy #2
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2901015672
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License Number State | MI
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