Provider Demographics
NPI:1174064539
Name:LAKESIDE PEDIATRIC DENTISTRY, LLC
Entity type:Organization
Organization Name:LAKESIDE PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-743-0901
Mailing Address - Street 1:1050 PARKSIDE CMNS
Mailing Address - Street 2:SUITE 103
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-4524
Mailing Address - Country:US
Mailing Address - Phone:706-454-2222
Mailing Address - Fax:706-454-1234
Practice Address - Street 1:1050 PARKSIDE CMNS
Practice Address - Street 2:SUITE 103
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642-4524
Practice Address - Country:US
Practice Address - Phone:706-454-2222
Practice Address - Fax:706-454-1234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty