Provider Demographics
NPI:1598243438
Name:LAKELAND DENTAL P.L.L.C.
Entity Type:Organization
Organization Name:LAKELAND DENTAL P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIC
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-280-0466
Mailing Address - Street 1:917 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:LONG PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:56347-1448
Mailing Address - Country:US
Mailing Address - Phone:320-732-6141
Mailing Address - Fax:
Practice Address - Street 1:917 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:LONG PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:56347
Practice Address - Country:US
Practice Address - Phone:320-732-6141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-02
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty