Provider Demographics
NPI:1356479539
Name:LAKE, MARK S (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:S
Last Name:LAKE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
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Mailing Address - Street 1:1037 PALISADES BLVD
Mailing Address - Street 2:STE 9
Mailing Address - City:OSAGE BEACH
Mailing Address - State:MO
Mailing Address - Zip Code:65065-3340
Mailing Address - Country:US
Mailing Address - Phone:573-348-9888
Mailing Address - Fax:573-348-9894
Practice Address - Street 1:1037 PALISADES BLVD
Practice Address - Street 2:STE 9
Practice Address - City:OSAGE BEACH
Practice Address - State:MO
Practice Address - Zip Code:65065-3340
Practice Address - Country:US
Practice Address - Phone:573-348-9888
Practice Address - Fax:573-348-9894
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20060147071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice