Provider Demographics
NPI:1053411645
Name:LAKESHORE FAMILY DENTAL, P.C.
Entity type:Organization
Organization Name:LAKESHORE FAMILY DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIDAS
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:NOREIKA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:219-872-2116
Mailing Address - Street 1:1232 E MICHIGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-4856
Mailing Address - Country:US
Mailing Address - Phone:219-872-2116
Mailing Address - Fax:219-874-7087
Practice Address - Street 1:1232 E MICHIGAN BLVD
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-4856
Practice Address - Country:US
Practice Address - Phone:219-872-2116
Practice Address - Fax:219-874-7087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54001178A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty