Provider Demographics
NPI:1568901866
Name:LAKE, JEFFREY MICHAEL (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:LAKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 S STONE AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85701-1914
Mailing Address - Country:US
Mailing Address - Phone:520-798-3384
Mailing Address - Fax:520-620-1246
Practice Address - Street 1:123 S STONE AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85701-1914
Practice Address - Country:US
Practice Address - Phone:520-798-3384
Practice Address - Fax:520-620-1246
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2017-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0096601223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics