Provider Demographics
NPI:1588950349
Name:ASSOCIATED ENDODONTISTS OF LAKE CITY
Entity type:Organization
Organization Name:ASSOCIATED ENDODONTISTS OF LAKE CITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECEIPTIONIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-758-6050
Mailing Address - Street 1:2086 SW MAIN BLVD STE 113
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2086 SW MAIN BLVD STE 113
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0006
Practice Address - Country:US
Practice Address - Phone:386-758-6050
Practice Address - Fax:386-758-7742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 54181223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty