Provider Demographics
NPI:1255604781
Name:LAKERIDGE DENTAL PARTNERS, PLLC
Entity type:Organization
Organization Name:LAKERIDGE DENTAL PARTNERS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIEWER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:218-847-9214
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56502-0517
Mailing Address - Country:US
Mailing Address - Phone:218-847-9214
Mailing Address - Fax:218-847-9215
Practice Address - Street 1:701 HIGHWAY 10 E
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-4219
Practice Address - Country:US
Practice Address - Phone:218-847-9214
Practice Address - Fax:218-847-9215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-14
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty