MEDICARE: LAKESIDE FAMILY DENTISTRY, PLLC

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	6796	OK

General Provider Information

NPI Number	:	1659860393
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAKESIDE FAMILY DENTISTRY, PLLC

Provider Business Mailing Address
First Line	:	2812 W HEFNER RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-6318
Country	:	US
Telephone Number	:	405-751-0358
Fax Number	:

Provider Business Practice Location Address
First Line	:	2812 W HEFNER RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-6318
Country	:	US
Telephone Number	:	405-751-0358
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS ADVISOR
Name	:	KRISTEN JOHNSON
Credential	:
Telephone Number	:	877-221-7750

Provider Enumeration Date	:	05/08/2018
Last Update Date	:	05/08/2018

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