Provider Demographics
NPI:1023275013
Name:LAKESHORE COMMUNITY DENTAL CLINIC
Entity type:Organization
Organization Name:LAKESHORE COMMUNITY DENTAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DEAN, HEALTH AND HUMAN SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, RN
Authorized Official - Phone:920-693-1386
Mailing Address - Street 1:1290 NORTH AVE
Mailing Address - Street 2:LAKESHORE COMMUNITY DENTAL CLINIC
Mailing Address - City:CLEVELAND
Mailing Address - State:WI
Mailing Address - Zip Code:53015-1412
Mailing Address - Country:US
Mailing Address - Phone:920-693-1386
Mailing Address - Fax:
Practice Address - Street 1:1290 NORTH AVE
Practice Address - Street 2:LAKESHORE COMMUNITY DENTAL CLINIC
Practice Address - City:CLEVELAND
Practice Address - State:WI
Practice Address - Zip Code:53015-1412
Practice Address - Country:US
Practice Address - Phone:920-693-1386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38394700Medicaid