| Lakewood Family Dental | |
|
1407 N Veterans Pkwy Suite 12 Bloomington IL 61704-6630 | |
| (732) 379-0953 | |
| Not Available |
| Full Name | Lakewood Family Dental |
|---|---|
| Speciality | Dentist - General Practice |
| Location | 1407 N Veterans Pkwy, Bloomington, Illinois |
| Authorized Official Name and Position | Srinivasulu Kakollu (PRESIDENT) |
| Authorized Official Contact | 7323790953 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Lakewood Family Dental 1407 N Veterans Pkwy Suite 12 Bloomington IL 61704-6630 Ph: (732) 379-0953 | Lakewood Family Dental 1407 N Veterans Pkwy Suite 12 Bloomington IL 61704-6630 Ph: (732) 379-0953 |
| NPI Number | 1154675304 |
|---|---|
| Provider Enumeration Date | 11/08/2012 |
| Last Update Date | 11/08/2012 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154675304 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 019-028401 (Illinois) | Primary |
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