Provider Demographics
NPI:1366840456
Name:NORTH LAKE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:NORTH LAKE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PATTY
Authorized Official - Middle Name:R
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:262-966-7668
Mailing Address - Street 1:W315N7641 HWY 83
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-9759
Mailing Address - Country:US
Mailing Address - Phone:262-966-7668
Mailing Address - Fax:
Practice Address - Street 1:W315N7641 HWY 83
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-9759
Practice Address - Country:US
Practice Address - Phone:262-966-7668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6346261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1982723920OtherNPI