Provider Demographics
NPI:1386035590
Name:MOORE LAKE DENTAL
Entity Type:Organization
Organization Name:MOORE LAKE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MURRAY
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:612-414-2182
Mailing Address - Street 1:6230 HIGHWAY 65 NE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FRIDLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55432-5107
Mailing Address - Country:US
Mailing Address - Phone:763-571-5497
Mailing Address - Fax:
Practice Address - Street 1:6230 HIGHWAY 65 NE
Practice Address - Street 2:SUITE 105
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-5107
Practice Address - Country:US
Practice Address - Phone:763-571-5497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND10520122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty