Provider Demographics
NPI:1083096085
Name:LAKE STREET FAMILY DENTAL PA
Entity Type:Organization
Organization Name:LAKE STREET FAMILY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:NELSON
Authorized Official - Last Name:HOLCOMBE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:763-350-6234
Mailing Address - Street 1:10799 251ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-4558
Mailing Address - Country:US
Mailing Address - Phone:763-350-6234
Mailing Address - Fax:
Practice Address - Street 1:119 LAKE ST S
Practice Address - Street 2:SUITE 1
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1576
Practice Address - Country:US
Practice Address - Phone:320-679-2435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-25
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13567122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty