Lakeside Dental Surgery Center

If you are interested in learning more about becoming a credentialed provider, please complete the information below so a member of our team can reach out to connect with you. For more information, please visit: Lakeside Dental Surgery Center - Provider Credentialing.

You can also give us a call at (904) 395-4840.
Full Name
First Last
Phone Number
Please enter a valid phone number.
Email
example@example.com

If you are currently an active credentialed provider of Lakeside Dental Surgery Center and would like to schedule a patient for treatment, please complete the patient referral form attached below, and e-mail it to the Patient Navigation Team at navigator@lakesidedentalsurgerycenter.com.

You can contact the Patient Navigation team at (904) 395-4840 with any questions.

Lakeside Dental Surgery Center encourages all eligible dental providers to become a credentialed provider at the facility. If the patient already has a dental home, please contact the dentist to schedule an appointment. If the dentist is a credentialed provider of Lakeside Dental Surgery Center then they will coordinate scheduling the case. If the dentist is not a credentialed dental provider and you wish for the patient to receive care at Lakeside Dental Surgery Center, please ask the dentist to submit a referral on our website.

Referring Dentist or Dental Practice*
Dentist or Dental Practice Name
Office Manager*
Your Practice's Case Coordinator
Dentist or Dental Practice Email*
example@example.com
Dental Practice Phone*
Relevant Medical or Dental History
Example: Patient suffers from asthma, or patient did not tolerate in-office treatment methods, etc.
Reason For Referral*
Example: Patient needs dental treatment under general anesthesia.
Please email any radiographs: navigator@lakesidedentalsurgerycenter.com

Patient's Name*
Patient's Date of Birth*
Responsible Party's Name*
Primary Language
Responsible Party's Phone Number*
Responsible Party's Email*
example@example.com
Relevant Patient Information*
Example: Patient has a toothache
Lakeside Dental Surgery Center is not an emergency facility. If the patient is experiencing a dental emergency, please seek care at a local emergency room.
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