Provider Demographics
NPI:1487868493
Name:LAKE COUNTRY DENTISTRY, L.L.C.
Entity Type:Organization
Organization Name:LAKE COUNTRY DENTISTRY, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:JON
Authorized Official - Last Name:COTEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-567-6003
Mailing Address - Street 1:175 E WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-3057
Mailing Address - Country:US
Mailing Address - Phone:262-567-6003
Mailing Address - Fax:262-567-6018
Practice Address - Street 1:175 E WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-3057
Practice Address - Country:US
Practice Address - Phone:262-567-6003
Practice Address - Fax:262-567-6018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental