Provider Demographics
NPI:1972145407
Name:LAKESHORE DENTAL STUDIO
Entity type:Organization
Organization Name:LAKESHORE DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CONNOR
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:617-416-8016
Mailing Address - Street 1:1221 W FAIRBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-1205
Mailing Address - Country:US
Mailing Address - Phone:407-794-1515
Mailing Address - Fax:
Practice Address - Street 1:1221 W FAIRBANKS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-1205
Practice Address - Country:US
Practice Address - Phone:407-794-1515
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental