Organization
LAKEWOOD FAMILY DENTAL INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SRINIVASULU KAKOLLU DDS (PRESIDENT)
(732) 379-0953
Entity
Organization
Contact information
Practice address
4512 PARNELL AVE, FORT WAYNE, IN 46825-5836
(732) 379-0953
Mailing address
1407 N VETERANS PKWY, SUITE 12, BLOOMINGTON, IL 61704-6630
(732) 379-0953
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
019028401
IL
Other
Enumeration date
04/02/2014
Last updated
04/03/2014
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