Provider Demographics
NPI:1093110215
Name:LAKE MERIDIAN DENTAL LLC
Entity Type:Organization
Organization Name:LAKE MERIDIAN DENTAL LLC
Other - Org Name:COMFORT DENTAL LAKE MERIDIAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PROBST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:253-631-3015
Mailing Address - Street 1:12906 SE KENT KANGLEY RD
Mailing Address - Street 2:
Mailing Address - City:KENT
Mailing Address - State:WA
Mailing Address - Zip Code:98030-7940
Mailing Address - Country:US
Mailing Address - Phone:253-631-3015
Mailing Address - Fax:
Practice Address - Street 1:12906 SE KENT KANGLEY RD
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-7940
Practice Address - Country:US
Practice Address - Phone:253-631-3015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60198294122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty