Provider Demographics
NPI:1255444634
Name:LAKE DENTAL SERVICES, P.A.
Entity type:Organization
Organization Name:LAKE DENTAL SERVICES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-274-2499
Mailing Address - Street 1:13195 SW 134 ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186
Mailing Address - Country:US
Mailing Address - Phone:305-274-2499
Mailing Address - Fax:
Practice Address - Street 1:820 STATE RD. 434 N.
Practice Address - Street 2:SUITE B
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714
Practice Address - Country:US
Practice Address - Phone:407-865-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty