Provider Demographics
NPI:1104056910
Name:LAKESIDE ENDODONTICS
Entity type:Organization
Organization Name:LAKESIDE ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KRADENPOTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-357-8747
Mailing Address - Street 1:10025 19TH AVE SE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-4275
Mailing Address - Country:US
Mailing Address - Phone:425-357-8747
Mailing Address - Fax:425-337-6190
Practice Address - Street 1:9505 19TH AVE SE STE 115
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3843
Practice Address - Country:US
Practice Address - Phone:425-357-8747
Practice Address - Fax:425-337-6190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-15
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty