Provider Demographics
NPI:1770003782
Name:LAKE EOLA DENTAL, INC.
Entity Type:Organization
Organization Name:LAKE EOLA DENTAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOANG
Authorized Official - Middle Name:
Authorized Official - Last Name:HO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:804-687-2817
Mailing Address - Street 1:338 N MAGNOLIA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-1639
Mailing Address - Country:US
Mailing Address - Phone:407-930-7007
Mailing Address - Fax:
Practice Address - Street 1:338 N MAGNOLIA AVE STE C
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32801-1639
Practice Address - Country:US
Practice Address - Phone:407-930-7007
Practice Address - Fax:407-930-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-21
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1396124509Medicaid