Provider Demographics
NPI:1801196134
Name:LAKE DENTAL OF SARATOGA, PC
Entity Type:Organization
Organization Name:LAKE DENTAL OF SARATOGA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOK KEEPER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DENNIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-817-2490
Mailing Address - Street 1:176 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-2529
Mailing Address - Country:US
Mailing Address - Phone:518-935-0068
Mailing Address - Fax:518-581-1145
Practice Address - Street 1:176 LAKE AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-2529
Practice Address - Country:US
Practice Address - Phone:518-935-0068
Practice Address - Fax:518-581-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0528451223G0001X
NY022051-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1710943774Medicaid
NY1467654178Medicaid