Provider Demographics
NPI:1184829509
Name:LAKE STREET DENTAL
Entity Type:Organization
Organization Name:LAKE STREET DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIOSONTIST
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:CAMARA
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:612-724-1717
Mailing Address - Street 1:1508 E LAKE ST
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1720
Mailing Address - Country:US
Mailing Address - Phone:612-724-1717
Mailing Address - Fax:
Practice Address - Street 1:1508 E LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1720
Practice Address - Country:US
Practice Address - Phone:612-724-1717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND118891223G0001X
MND117181223P0300X
MND120071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty