Provider Demographics
NPI:1205288982
Name:LAKESIDE ORAL & FACIAL SURGERY INSTITUTE
Entity type:Organization
Organization Name:LAKESIDE ORAL & FACIAL SURGERY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL & MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:847-328-8899
Mailing Address - Street 1:2500 RIDGE AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-2455
Mailing Address - Country:US
Mailing Address - Phone:847-328-8899
Mailing Address - Fax:847-563-1350
Practice Address - Street 1:2500 RIDGE AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-2455
Practice Address - Country:US
Practice Address - Phone:847-328-8899
Practice Address - Fax:847-563-1350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-06
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021002718261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery