Provider Demographics
NPI:1619446077
Name:CORDELL LAKE, D.D.S., LLC
Entity Type:Organization
Organization Name:CORDELL LAKE, D.D.S., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CORDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-728-1630
Mailing Address - Street 1:3145 CROSS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:CAMDENTON
Mailing Address - State:MO
Mailing Address - Zip Code:65020-9377
Mailing Address - Country:US
Mailing Address - Phone:816-728-1630
Mailing Address - Fax:
Practice Address - Street 1:12 E HARRISON ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1859
Practice Address - Country:US
Practice Address - Phone:573-756-4344
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental