Provider Demographics
NPI:1275804312
Name:LAKE FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:LAKE FAMILY DENTISTRY PC
Other - Org Name:LAKE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANISH
Authorized Official - Middle Name:
Authorized Official - Last Name:QADRI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-388-2822
Mailing Address - Street 1:296 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-1201
Mailing Address - Country:US
Mailing Address - Phone:732-388-2822
Mailing Address - Fax:732-388-3115
Practice Address - Street 1:296 LAKE AVE
Practice Address - Street 2:
Practice Address - City:COLONIA
Practice Address - State:NJ
Practice Address - Zip Code:07067-1201
Practice Address - Country:US
Practice Address - Phone:732-388-2822
Practice Address - Fax:732-388-3115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-21
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02351300261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental