Provider Demographics
NPI:1417329988
Name:LAKEHAVEN DENTAL
Entity Type:Organization
Organization Name:LAKEHAVEN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HACKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-787-7900
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:LANGLEY
Mailing Address - State:OK
Mailing Address - Zip Code:74350-0339
Mailing Address - Country:US
Mailing Address - Phone:918-782-9744
Mailing Address - Fax:
Practice Address - Street 1:758 HWY 28
Practice Address - Street 2:
Practice Address - City:LANGLEY
Practice Address - State:OK
Practice Address - Zip Code:74350-0339
Practice Address - Country:US
Practice Address - Phone:918-782-9744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAKEHAVEN DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty