Provider Demographics
NPI:1073593976
Name:LAKEBRINK, THOMAS G (DDS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:LAKEBRINK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N STEWART CT
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068
Mailing Address - Country:US
Mailing Address - Phone:816-792-4455
Mailing Address - Fax:816-792-8767
Practice Address - Street 1:105 N STEWART CT
Practice Address - Street 2:SUITE 140
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068
Practice Address - Country:US
Practice Address - Phone:816-792-4455
Practice Address - Fax:816-792-8767
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014423122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist