Provider Demographics
NPI:1942986476
Name:LAKE STATE DENTAL PLLC
Entity Type:Organization
Organization Name:LAKE STATE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:
Authorized Official - First Name:CLAIRE
Authorized Official - Middle Name:
Authorized Official - Last Name:STICKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-841-0871
Mailing Address - Street 1:519 COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2405
Mailing Address - Country:US
Mailing Address - Phone:302-841-0871
Mailing Address - Fax:
Practice Address - Street 1:401 N LAKEVIEW AVE
Practice Address - Street 2:
Practice Address - City:STURGIS
Practice Address - State:MI
Practice Address - Zip Code:49091-1229
Practice Address - Country:US
Practice Address - Phone:302-841-0871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental