MEDICARE: LAKESHORE COMMUNITY DENTAL CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023275013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESHORE COMMUNITY DENTAL CLINIC

Provider Business Mailing Address
First Line	:	1290 NORTH AVE
Second Line	:	LAKESHORE COMMUNITY DENTAL CLINIC
City	:	CLEVELAND
State	:	WI
Zip	:	53015-1412
Country	:	US
Telephone Number	:	920-693-1386
Fax Number	:

Provider Business Practice Location Address
First Line	:	1290 NORTH AVE
Second Line	:	LAKESHORE COMMUNITY DENTAL CLINIC
City	:	CLEVELAND
State	:	WI
Zip	:	53015-1412
Country	:	US
Telephone Number	:	920-693-1386
Fax Number	:

Authorized Official
Title or Position	:	DEAN, HEALTH AND HUMAN SERVICES
Name	:	MS. BARBARA J DODGE
Credential	:	PH.D., R.N.
Telephone Number	:	920-693-1386

Provider Enumeration Date	:	05/19/2008
Last Update Date	:	05/19/2008

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Directions to “LAKESHORE COMMUNITY DENTAL CLINIC ” Practice Location

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