Provider Demographics
NPI:1427027184
Name:SOUTH LAKE CLINIC, P.A.
Entity Type:Organization
Organization Name:SOUTH LAKE CLINIC, P.A.
Other - Org Name:SOUTH LAKE PEDIATRICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:T
Authorized Official - Last Name:DOBRIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:952-401-8300
Mailing Address - Street 1:17705 HUTCHINS DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55345-4145
Mailing Address - Country:US
Mailing Address - Phone:952-401-8300
Mailing Address - Fax:952-401-8240
Practice Address - Street 1:17705 HUTCHINS DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55345-4145
Practice Address - Country:US
Practice Address - Phone:952-401-8300
Practice Address - Fax:952-401-8240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN556208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN16623SOOtherBCBS