Provider Demographics
NPI:1255490389
Name:LAKES DENTAL ASSOC PA
Entity Type:Organization
Organization Name:LAKES DENTAL ASSOC PA
Other - Org Name:LAKES DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:STRENSRUD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:651-257-3246
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025
Mailing Address - Country:US
Mailing Address - Phone:651-257-3246
Mailing Address - Fax:651-464-6857
Practice Address - Street 1:956 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025
Practice Address - Country:US
Practice Address - Phone:651-464-7277
Practice Address - Fax:651-464-6857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8907122300000X
MN89338122300000X
MN11000122300000X
MN9362122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty