Provider Demographics
NPI:1215058532
Name:LAKESHORE FAMILY DENTAL CARE SC
Entity type:Organization
Organization Name:LAKESHORE FAMILY DENTAL CARE SC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:OSHIRO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-639-1272
Mailing Address - Street 1:PO BOX 044290
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53404
Mailing Address - Country:US
Mailing Address - Phone:262-639-1272
Mailing Address - Fax:262-639-8870
Practice Address - Street 1:3903 DOUGLAS AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402
Practice Address - Country:US
Practice Address - Phone:262-639-1272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3520122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
33487600OtherEDS TITLE 19