Provider Demographics
NPI:1376143081
Name:LAKE CITY DENTAL CLINIC
Entity Type:Organization
Organization Name:LAKE CITY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHIDDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-944-2331
Mailing Address - Street 1:PO BOX 999
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81235-0999
Mailing Address - Country:US
Mailing Address - Phone:970-944-2331
Mailing Address - Fax:970-944-2320
Practice Address - Street 1:700 N HENSON ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:CO
Practice Address - Zip Code:81235-5134
Practice Address - Country:US
Practice Address - Phone:970-944-2331
Practice Address - Fax:970-944-2320
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000141620Medicaid