Provider Demographics
NPI:1821187683
Name:LAKE, ULRICH (DDS)
Entity Type:Individual
Prefix:DR
First Name:ULRICH
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 RIVER PLACE
Mailing Address - Street 2:STE 110
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716
Mailing Address - Country:US
Mailing Address - Phone:608-222-6160
Mailing Address - Fax:608-222-6248
Practice Address - Street 1:100 RIVER PLACE
Practice Address - Street 2:STE 110
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716
Practice Address - Country:US
Practice Address - Phone:608-222-6160
Practice Address - Fax:608-222-6248
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42880151223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33762600Medicaid