NPIMap

Organization Active NPI

Lakewood Family Dental

  • General Practice Dentistry
  • Bloomington, IL
National Provider Identifier
1154675304
Registry record updated Nov 8, 2012
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice DentistryTaxonomy code 1223G0001X
License
019-028401 Issued in IL
Legal business name
LAKEWOOD FAMILY DENTAL
Practice address
1407 N Veterans Pkwy
Suite 12
Bloomington, IL 61704-6630
Phone
(732) 379-0953
NPI assigned
Nov 8, 2012
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 8, 2012

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Srinivasulu Kakollu, DDSNPI 1265744189
Title
President
Phone
(732) 379-0953

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
General Practice DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223G0001X 019-028401 IL Primary

Addresses

Primary practice location

1407 N Veterans Pkwy
Suite 12
Bloomington, IL 61704-6630

Mailing address

1407 N Veterans Pkwy
Suite 12
Bloomington, IL 61704-6630
Phone (732) 379-0953

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1352332800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1352332800000",
    "number": "1154675304",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1407 N VETERANS PKWY",
            "address_2": "SUITE 12",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617046630",
            "telephone_number": "732-379-0953"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1407 N VETERANS PKWY",
            "address_2": "SUITE 12",
            "city": "BLOOMINGTON",
            "state": "IL",
            "postal_code": "617046630",
            "telephone_number": "732-379-0953"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKEWOOD FAMILY DENTAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2012-11-08",
        "last_updated": "2012-11-08",
        "status": "A",
        "authorized_official_last_name": "KAKOLLU",
        "authorized_official_first_name": "SRINIVASULU",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "732-379-0953",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DDS"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "IL",
            "license": "019-028401",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Bloomington, IL

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.