Provider Demographics
NPI:1942557368
Name:LAKEBRINK DENTAL
Entity Type:Organization
Organization Name:LAKEBRINK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:G
Authorized Official - Last Name:LAKEBRINK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-792-4455
Mailing Address - Street 1:105 N STEWART CT
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-1066
Mailing Address - Country:US
Mailing Address - Phone:816-792-4455
Mailing Address - Fax:
Practice Address - Street 1:105 N STEWART CT
Practice Address - Street 2:SUITE 140
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1066
Practice Address - Country:US
Practice Address - Phone:816-792-4455
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-06
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO144231223G0001X
MO20110145251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty