Provider Demographics
NPI:1356614838
Name:LAKSHORE FAMILY DENTAL
Entity type:Organization
Organization Name:LAKSHORE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:BARGREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-429-4661
Mailing Address - Street 1:5638 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENSVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49127-9696
Mailing Address - Country:US
Mailing Address - Phone:269-429-4661
Mailing Address - Fax:269-429-4486
Practice Address - Street 1:5638 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9696
Practice Address - Country:US
Practice Address - Phone:269-429-4661
Practice Address - Fax:269-429-4486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-15
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019195122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty