# LAKEWOOD FAMILY DENTAL INC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1386062768
- **Authorized official:** DR. SRINIVASULU KAKOLLU DDS (PRESIDENT)
- **Authorized official phone:** (732) 379-0953

## Contact information

- **Practice address:** 4512 PARNELL AVE, FORT WAYNE, IN 46825-5836
- **Practice address phone:** (732) 379-0953
- **Mailing address:** 1407 N VETERANS PKWY, SUITE 12, BLOOMINGTON, IL 61704-6630
- **Mailing address phone:** (732) 379-0953

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 019028401 | IL | Yes |

## Other

- **Enumeration date:** 04/02/2014
- **Last updated:** 04/03/2014