Provider Demographics
NPI:1760637185
Name:LAKES REGIONAL ORAL & MAXILLOFACIAL SURGERY, PC
Entity Type:Organization
Organization Name:LAKES REGIONAL ORAL & MAXILLOFACIAL SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVELHOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:712-264-8390
Mailing Address - Street 1:116 E 11TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4364
Mailing Address - Country:US
Mailing Address - Phone:712-264-8390
Mailing Address - Fax:712-264-8391
Practice Address - Street 1:116 E 11TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4364
Practice Address - Country:US
Practice Address - Phone:712-264-8390
Practice Address - Fax:712-264-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-26
Last Update Date:2008-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty