MEDICARE: DR. LAKEISHA NICOLE THICKLIN D.D.S.

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	1223G0001X	General Practice Dentistry	30.24828	OH

General Provider Information

NPI Number	:	1053793950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAKEISHA NICOLE THICKLIN D.D.S.

Provider Business Mailing Address
First Line	:	3867 NORTHAMPTON RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-2067
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3867 NORTHAMPTON RD
Second Line	:
City	:	CLEVELAND HEIGHTS
State	:	OH
Zip	:	44121-2067
Country	:	US
Telephone Number	:	216-583-5061
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2015
Last Update Date	:	06/21/2016

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