Provider Demographics
NPI:1407878978
Name:LAKES DENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:LAKES DENTAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:C
Authorized Official - Last Name:MARTINEAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-546-2101
Mailing Address - Street 1:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:THREE LAKES
Mailing Address - State:WI
Mailing Address - Zip Code:54562-0410
Mailing Address - Country:US
Mailing Address - Phone:715-546-2101
Mailing Address - Fax:715-546-4331
Practice Address - Street 1:1858 SUPERIOR ST.
Practice Address - Street 2:
Practice Address - City:THREE LAKES
Practice Address - State:WI
Practice Address - Zip Code:54562-0410
Practice Address - Country:US
Practice Address - Phone:715-546-2101
Practice Address - Fax:715-546-4331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50020651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33373200Medicaid