Provider Demographics
NPI:1093172561
Name:LAKE PLEASANT DENTISTRY PC
Entity Type:Organization
Organization Name:LAKE PLEASANT DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BADER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-825-5595
Mailing Address - Street 1:9059 W LAKE PLEASANT PKWY
Mailing Address - Street 2:STE F 600
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-8336
Mailing Address - Country:US
Mailing Address - Phone:623-825-5595
Mailing Address - Fax:623-825-5129
Practice Address - Street 1:9059 W LAKE PLEASANT PKWY
Practice Address - Street 2:STE F 600
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-8336
Practice Address - Country:US
Practice Address - Phone:623-825-5595
Practice Address - Fax:623-825-5129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty