Provider Demographics
NPI:1063757912
Name:LAKES MALL DENTAL CENTER , PA
Entity type:Organization
Organization Name:LAKES MALL DENTAL CENTER , PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:O
Authorized Official - Last Name:CALDERON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:305-951-9988
Mailing Address - Street 1:1830 S OCEAN DR APT 2204
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-7695
Mailing Address - Country:US
Mailing Address - Phone:305-951-9988
Mailing Address - Fax:
Practice Address - Street 1:11401 PINES BLVD STE 220
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-4104
Practice Address - Country:US
Practice Address - Phone:954-432-5515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL193771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty