Provider Demographics
NPI:1578682050
Name:LAKES DENTAL CARE PLC
Entity Type:Organization
Organization Name:LAKES DENTAL CARE PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:E
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-829-4511
Mailing Address - Street 1:31052 GOVERMENT DR
Mailing Address - Street 2:P.O. BOX 426
Mailing Address - City:PEQUOT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56472-1002
Mailing Address - Country:US
Mailing Address - Phone:218-568-5011
Mailing Address - Fax:218-568-6851
Practice Address - Street 1:31052 GOVERMENT DR
Practice Address - Street 2:
Practice Address - City:PEQUOT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56472-1002
Practice Address - Country:US
Practice Address - Phone:218-568-5011
Practice Address - Fax:218-568-6851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN27172061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty