Provider Demographics
NPI:1639310089
Name:LAKE HARBOR DENTAL
Entity Type:Organization
Organization Name:LAKE HARBOR DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, PA
Authorized Official - Phone:208-853-4687
Mailing Address - Street 1:5355 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3333
Mailing Address - Country:US
Mailing Address - Phone:208-853-4687
Mailing Address - Fax:208-853-4690
Practice Address - Street 1:5355 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3333
Practice Address - Country:US
Practice Address - Phone:208-853-4687
Practice Address - Fax:208-853-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD30441223G0001X
IDD41421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty