Provider Demographics
NPI:1487862009
Name:JOHN F LAKE DDS & DEBORAH STARR
Entity Type:Organization
Organization Name:JOHN F LAKE DDS & DEBORAH STARR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:F
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-889-7050
Mailing Address - Street 1:286 SW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2610
Mailing Address - Country:US
Mailing Address - Phone:541-889-7050
Mailing Address - Fax:541-889-6495
Practice Address - Street 1:286 SW 4TH ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2610
Practice Address - Country:US
Practice Address - Phone:541-889-7050
Practice Address - Fax:541-889-6495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR226330Medicaid
ID805738900Medicaid
ID805738800Medicaid
OR226329Medicaid