Provider Demographics
NPI:1316253149
Name:GREAT LAKES DENTALOF WESTLAKE LLC
Entity type:Organization
Organization Name:GREAT LAKES DENTALOF WESTLAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:STAFANI
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDOVAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-356-2089
Mailing Address - Street 1:19111 DETROIT RD STE 206
Mailing Address - Street 2:
Mailing Address - City:ROCKY RIVER
Mailing Address - State:OH
Mailing Address - Zip Code:44116-1740
Mailing Address - Country:US
Mailing Address - Phone:440-617-9429
Mailing Address - Fax:440-356-2090
Practice Address - Street 1:25101 DETROIT RD
Practice Address - Street 2:SUITE 445
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-2552
Practice Address - Country:US
Practice Address - Phone:440-617-9429
Practice Address - Fax:440-617-9457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-31
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0224361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty