Provider Demographics
NPI:1659861599
Name:JAMES LAKE DDS INC
Entity Type:Organization
Organization Name:JAMES LAKE DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-365-0774
Mailing Address - Street 1:57340 29 PALMS HWY
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-2927
Mailing Address - Country:US
Mailing Address - Phone:760-365-0774
Mailing Address - Fax:760-365-3995
Practice Address - Street 1:57340 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-2927
Practice Address - Country:US
Practice Address - Phone:760-365-0774
Practice Address - Fax:760-365-3995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA596571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty