Provider Demographics
NPI:1376639963
Name:LAKES, STEVEN CHARRLES
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:CHARRLES
Last Name:LAKES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 166
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415
Mailing Address - Country:US
Mailing Address - Phone:860-537-1444
Mailing Address - Fax:860-537-6648
Practice Address - Street 1:151 BROADWAY
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415
Practice Address - Country:US
Practice Address - Phone:860-537-1444
Practice Address - Fax:860-537-6648
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5290122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist