Provider Demographics
NPI:1114048121
Name:LAKE, VALERIE E (DDS)
Entity Type:Individual
Prefix:DR
First Name:VALERIE
Middle Name:E
Last Name:LAKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:VALERIE
Other - Middle Name:E
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS LLC
Mailing Address - Street 1:6211 COVINGTON RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7311
Mailing Address - Country:US
Mailing Address - Phone:260-432-1579
Mailing Address - Fax:260-432-4540
Practice Address - Street 1:6211 COVINGTON RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-7311
Practice Address - Country:US
Practice Address - Phone:260-432-1579
Practice Address - Fax:260-432-4540
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010452A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice