Provider Demographics
NPI:1508984410
Name:LAKES AREA MOBILE SMILES, INC
Entity Type:Organization
Organization Name:LAKES AREA MOBILE SMILES, INC
Other - Org Name:LAKES MOBILE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:218-831-3131
Mailing Address - Street 1:22187 STATE HIGHWAY 6
Mailing Address - Street 2:
Mailing Address - City:DEERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56444-6279
Mailing Address - Country:US
Mailing Address - Phone:218-831-3131
Mailing Address - Fax:612-235-3391
Practice Address - Street 1:22187 STATE HIGHWAY 6
Practice Address - Street 2:
Practice Address - City:DEERWOOD
Practice Address - State:MN
Practice Address - Zip Code:56444-6279
Practice Address - Country:US
Practice Address - Phone:218-831-3131
Practice Address - Fax:612-235-3391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty