Provider Demographics
NPI:1962013813
Name:LAKE COUNTRY ORTHODONTICS
Entity Type:Organization
Organization Name:LAKE COUNTRY ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-226-2331
Mailing Address - Street 1:1119 WALNUT DR STE 4
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2360
Mailing Address - Country:US
Mailing Address - Phone:580-226-2331
Mailing Address - Fax:580-226-8776
Practice Address - Street 1:1119 WALNUT DR STE 4
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2360
Practice Address - Country:US
Practice Address - Phone:580-226-2331
Practice Address - Fax:580-226-8776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty