Provider Demographics
NPI:1275673444
Name:LAKE, DEBRA E (DMD)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:E
Last Name:LAKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:E
Other - Last Name:MATTOX, HOWARD, MULLINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:530 DOE RUN RD
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:KY
Mailing Address - Zip Code:41010-6007
Mailing Address - Country:US
Mailing Address - Phone:218-565-1483
Mailing Address - Fax:
Practice Address - Street 1:530 DOE RUN RD
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:KY
Practice Address - Zip Code:41010-6007
Practice Address - Country:US
Practice Address - Phone:218-565-1483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5569-015122300000X
FLDN 13258122300000X
KY80241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist